CARE HOMES FOR OLDER PEOPLE
Hope Cottage 5-7 Pilkington Road Southport Merseyside PR8 6PD Lead Inspector
Mr Mike Perry Unannounced Inspection 21st June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hope Cottage DS0000051273.V301335.R02.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. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hope Cottage Address 5-7 Pilkington Road Southport Merseyside PR8 6PD 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) 01704 536286 Hope Cottage Limited Mrs Joan White Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 26 DE (E) The service should employ a suitably qualified and experienced Manager who is registered with the CSCI. 6th January 2006 Date of last inspection Brief Description of the Service: Hope Cottage is a residential care home that specialises in caring for older people with dementia. The home is Registered for 26 residents and is owned by Hope Cottage Ltd. The Responsible Person is Mr T Yilmaz. The Manager is Joan White. Hope Cottage is situated within a suburb of Southport and is within easy reach of the town centre [1 mile]. The home has been extended to include a conservatory and further bedrooms, bathrooms and toilets. The facilities are spread over 2 floors with a passenger lift serving the first floor. All communal space is on the ground floor and includes lounge, conservatory and dining room facilities. There is an enclosed garden to the rear of the building and parking space at the front. A ramp has been added to provide disabled access. 3 of the bedrooms can provide for residents to share. The current fees at the home range between £394.50 - £405.00 per week. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was a ‘key’ inspection for the service and covered the core Standards the home is expected to achieve. The inspection took place over a period of 8 hours over 1 day. The inspector met with residents and spoke with relatives who were visiting the home. The inspector also spoke with members of care staff on a one to one basis and the registered Provider. A tour of the premises was carried out and this covered all areas of the home including the resident’s rooms [not all bedrooms were seen]. Records were examined and these included three of the resident’s care plans, staff files, staff training records and health and safety records as well as quality audits. What the service does well:
The relatives interviewed felt that they had had sufficient information in the form of a brouchure and service user guide and that this had been helpful. An assessment of needs is in place for each of the residents. The assessments include information on the residents mental health. The home attains assessments and care plans from relevant professionals; for example from care managers and community nurses. Each of the residents has a separate record of their social history and this is used to build a picture of the person and to inform staff as to the activities and interests they could be included in at the home. The home manages the health care of residents well. One resident was having regular input from district nurses. Staff were knowledgeable regarding this residents condition and were able to carry out the daily care. There was also appropriate medical referral ongoing. All care plans displayed varying levels of resident / relative involvement. It was noted that relatives are invited to care planning meetings on a regular basis and these are documented. It was clear from talking to relatives that the staff ensure that relatives are kept up to date with any changes in the care. One Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 6 relative commented ‘the staff are very good they always phone or discuss any events that occur’. Residents observed were clean and appropriately dressed. Relatives were pleased with the staffs approach to personal care and said that the residents are ‘always clean and tidy and clothing is well cared for’. Staff interviewed understood the importance of maintaining dignity for residents and were observed to be patient when giving care. The general atmosphere in the home is warm and friendly and visitors spoken to commented this on. There is a monthly activity programme advertised and staff fill in other times with various games, craft pastimes, sitting out in the garden and some reminiscence sessions. Both staff and relatives spoken to felt that this programme could be built on further. Staff interviewed were aware of individual residents likes and dislikes in terms of dress and food preference. Individual bedrooms displayed photographs and ornaments, which reflected individual’s history and personality. Relatives felt free to visit at any time and found staff welcoming and helpful. The home has a conservatory at the rear of the building overlooking the garden and relatives felt that this was useful if they wanted a bit more privacy when visiting. Mealtime was observed and residents clearly enjoyed what was a relaxed social occasion. Tables are laid with tablecloths and fresh flowers. All meals are freshly prepared. Joan White is the Registered Manager. Staff felt that they received good support from her and that she was approachable. The senior staff present were, for the most part able to access the information asked for and the systems in place generally supported the staff in the managers absence. The home undergoes an external audit on a yearly basis in order to monitor and improve quality. Resident and relative feedback is canvassed on a 6 monthly basis and the comments seen were very positive Staff were clear about the policy in the home for managing residents monies and safekeeping of valuables and were able to explain this. Relatives said that any finance issues were addressed promptly. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
On the day of the inspection the brouchure was available but the Service User Guide was not. Following discussion it was agreed that the guide should be immediately available in case of any requests or enquiries. The care plans seen, although giving a satisfactory overall idea if the care, could be more detailed around identifying needs and giving more specific interventions. For example one resident who has a catheter is referenced in the care plan but there could be more detail around the observations needed and care to the catheter on a daily basis. Evaluations of the care plan are indicated on a form which consists of dates but no notes. Evaluating how effective the care is should be a discussion of progress made against the goals set on the care plan rather than just a recording of a date. One resident was on some PRN [give when required] medication. This was not referenced on the care plan however so that there is a risk of staff being inconsistent in interpreting when the medication should be given. It was not clear from the records on what basis the medicine was being administered. A review was advised. Staff spoken to were not wholly clear about how to complete referrals for any allegations of mistreatment or abuse and all senior staff should be aware of the protocols. The planned training for staff in this area should continue. The hot water was tested for temperature in two bathrooms and was recorded at over 50C. An immiediate requirment was given to ensure that thermostatic controls are set to ensure a safe temperature [43C]. [ This was checked on 22.6.06 and arrangments had been made to address the problem]. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 8 Accident records were discussed and a recent example of an accident record inspected. The record however only showed ‘no apparent injury’ and the importance of recording more detail was discussed. 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. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 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 Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 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): 1,3 [standard 6 not applicable] The quality in this outcome area is good. The home provides information for prospective residents and their relatives so that an effective choice can be made to move into the home. The Service user guide should be available at all times however. Appropriate assessments are carried out by the home, which include social service and / or health assessments so that the home is better able to ensure care needs will be met. EVIDENCE: Standard 1 around the information supplied to service users prior to and during addmission was not assessed in any detail. The relatives interviewed felt that they had had sufficient information in the form of a brouchure and service user guide and that this had been helpful. On the day of the inspection the brouchure was available but the Service User Guide was not. Following
Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 11 discussion it was agreed that the Guide should be immediatly available in case of any requests or enquiries. Assessment information was looked at for three residents. An assessment of needs is in place for each of the residents. These assessments have been completed by a senior member of staff at the home. The assessments include information on the residents mental health. The home attains assessments and care plans from relevant professionals for example from care managers and community nurses. In addition to the general assessment there are additional assessments for issues such as any risks associated with the resident’s care. Each of the residents has a separate record of their social history and this describes things such as the person background, previous employment, interests and is used to build a picture of the person and to inform staff as to the activities and interests they could be included in at the home. Not all of the assessments were signed and dated. From the assessments a plan of care can be drawn up. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality in this outcome area is adequate. The home manages the health care needs of residents satisfactorily but some health care needs could be specified better on care plans. Personal care needs are met consitently so that residents are treated with respect and their dignity maintained. EVIDENCE: All residents have a plan of care. These were discussed in detail on the previous inspection and some general requirements were made around trying to ensure more depth and consistency as the clarity of the care plans vary. For example the care plans seen, although giving a satisfactory overall idea if the care, could be more detailed around identifying needs and giving more specific interventions. These findings were similar on this inspection. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 13 For example one resident who has a catheter is referenced in the care plan but there could be more detail around the observations needed and care to the catheter on a daily basis. Staff spoken to were, however, able to relate the care needed and the care was actually being carried out. The resident was on a fluid intake chart [not referenced on the care plan], which was filled in and up to date. There has been appropriate liaison with the district nursing team who were visiting regularly. There are also appropriate medical referrals ongoing. All care plans displayed varying levels of resident / relative involvement. It was noted that relatives are invited to care planning meetings on a regular basis and these are documented. It would be a useful idea for the notes of these meetings to reference discussion of the care plan. The care plans are based around a model of care called ‘Activities of daily living’ so that staff can assess and plan care around routine daily activities such as washing, eating and self care. Reviews / evaluations of the care plan are indicated on a form which consists of dates but no notes. the concept of evaluation has been discussd with the manager, previosly and agreement reached that this should be a discussion and evaluation of progress made against the goals set on the care plan rather than just a recording of the date. Over all however it was clear from talking to relatives that the staff ensure that relatives are kept up to date with any changes in the care. One relative commented ‘the staff are very good they always phone or discuss any events that occur’. The home has medication policies and procedures and the staff interviewed were aware of these. Due to issues of mental capacity there are no residents self-medicating although there is a procedure available if required. Following previous requirements the practice on nights has been change so there is no secondary dispensing of medicines. All staff have also received training in medication administration. Medication administration records [MAR] were seen. One resident was on some PRN [give when required] medication. One staff identified that that this should be given ‘when the resident was agitated’. This was not referenced on the care plan however so that there is a risk of staff being inconsistent in interpreting when the medication should be given. This was further evidenced by the fact that records show the medication had been given consistently each evening at 20:00 for the past month indicating that the medicine should be prescribed on a permanent basis at this time or possible staff were simply giving the medication as a matter of routine. A review was advised. Residents observed were clean and appropriately dressed. Relatives were pleased with the staffs approach to personal care and said that the residents
Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 14 are ‘always clean and tidy and clothing is well cared for’. Staff interviewed understood the importance of maintaining dignity for residents and were observed to be patient in any care interventions such as assisting with feeding or toileting. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 15 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): 12,13,14,15 The quality in this outcome area is good. Residents are supported to be involved in activities. Residents are encouraged to maintain their independence and exercise choice. A choice of good quality home cooked food is provided to the residents who eat in very pleasant surroundings. EVIDENCE: The general atmosphere in the home is warm and friendly and visitors spoken to commented this on. There are some activities planned for residents, which tend to take place in the afternoons. There is a monthly activity programme advertised and staff fill in other times with various games, craft pastimes, sitting out in the garden and some reminiscence sessions. Both staff and relatives spoken to felt that this programme could be built on. There could be more craft material for example. The home could get a daily newspaper to discuss the day’s events with some residents. One relative
Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 16 commented that residents should get out more and was surprised that a mini bus was not available for trips. The personal exercise of choice and control over resident’s daily life in the home is a difficult balance to achieve given the lack of mental capacity of the resident group. There were examples however of how the home were trying to achieve a good balance. For example staff interviewed were aware of individual residents likes and dislikes in terms of dress and food preference. Individual bedrooms displayed photographs and ornaments, which reflected individual’s history and personality. Personal furnishings are discussed on admission with relatives. One resident was seen who had his own TV and also had evidence of past hobbies in his room, which he was able to talk about. Relatives felt free to visit at any time and found staff welcoming and helpful. The home has a conservatory at the rear of the building overlooking the garden and relatives felt that this was useful if they wanted a bit more privacy when visiting. Mealtime was observed and residents clearly enjoyed what was a relaxed social occasion. The menu is displayed and residents are offered a choice of meal as care staff ask daily for residents preferences. Tables are laid with tablecloths and fresh flowers. The meal served looked appetising and residents said that they had enjoyed it. All meals are freshly prepared. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 17 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): The quality in this outcome area is adequate. There is a complaints procedure including action for more serious allegations so that residents rights are upheld and people feel that concerns are addressed. The issue of formall training for abuse awarness for all staff still needs to be adressed. EVIDENCE: There is a complaints procedure in the home and this is in the Service User Guide as well as being displayed. Staff were able to describe how complaints are managed and the complaints files and complaints book were seen. Relatives said that the management were very approachable and one stated ‘ you only have to mention something and the staff will do something about it. There have been no complaints made through The Commissions since the last inspection. The Home has policies around the Protection of Vulnerable Adults and contact information for referrals is available on the notice board in the manager’s office. Staff spoken to were not wholly clear about how to complete referrals however and all senior staff should be aware of the protocols. There has been some recent training in the Protection of Vulnerable adults but not all staff have attended although the inspector was told this would be facilitated.
Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 18 Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 19 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): 19,25,26 The quality in this outcome area is adequete. The presentation of the home continues to improve. Residents are provided with a safe, comfortable and homely environment in which to live. EVIDENCE: A tour of the premises was carried out. The home is not purpose built for caring for people with dementia as the bedrooms are over 3 floors and there for not immiediatley accessible. The home feels domestic and welcoming however and has undergone some refurbishment since the last inspection and requirments and recommendations have been acted on. The programme of covering radiators to protect residents from burns is now complete. The toilets on the ground floor near the day room have been converted to a single disabled facility and new carpets have been fitted in the lounge.
Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 20 Externally the gardens are safe for residents to access and there has been ongoing maintainance carried out [windows replaced over the past few years] There was an ongoign maintainance plan in the managers office. All bedrooms are very well personalised. It is clear to see that staff have spent some time getting family to bring in photos and ornaments and various memorabillia. All rooms are clean and tidy and the quality of bedding and furnishings is very good. Shared rooms have curtain screens to ensure privacy. There was some discussion around the use of names signs and photographs on doors to identify bedrooms and other areas in the home which may assist orientating residents. There is a choice of bathing facilities, both assisted and unassisted and there is a walk in shower. The hot water was tested for temperature in two bathrooms and was recorded at over 50C. An immiediate requirment was given to ensure that thermostatic controls are set to ensure a safe temperature [43C]. The problem the home had in the past regarding unpleasant oudours has now been eradicated. All areas of the home seen were clean and tidy. Visitors commented that this standard is maintained. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 21 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 The quality in this outcome area is good. Staff numbers are appropriate and service user’s needs are being met effectively and promptly. There is an ongoing training programme which include reference to dementia care so that staff are aware of and can meet the needs of residents. Staff are recruited appropriately so that residents are protected. EVIDENCE: On the day of the inspection the home had 24 residents and was staffed with a senior carer and 3 care assistants. The manager was on holiday at the time and would normally be in addition to these figures for 18 hours per week. There was also ancillary staff working in the kitchen and for cleaning and laundry. The duty rota confirmed regular staffing numbers. There is 15 care staff in total and 6 of these currently have an NVQ qualification at level 2 or above [40 ]. NVQ training is ongoing in the home and all staff interviewed were involved to varying degrees [7 staff currently training. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 22 Staff interviewed felt that the training provided was good and some of this related directly to dementia care. For example 5 staff have recently attended a full days update on dementia. Staff discussed the in house workbooks and has periodicals to keep up to date with dementia care. There was recognition from the senior staff member spoken to of the diverse need of the residents and how challenging behaviour needs to be looked at and assessed individually. Training around the subject of dementia should be integral and woven into the ongoing programme of training. Other recommended training would be on activities for people with dementia and also interventions for challenging behaviour. Relatives stated that staff are very caring and they were confident that the needs of residents are understood. The recruitment processes are good. Staff files were inspected and all of the necessary checks to ensure that staff are fit to be employed with vulnerable adults were in place. Staff spoken to who had been more recently employed felt that the process had been thorough. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 23 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 The quality in this outcome area is adequate. The manager of the home displays the skills and knowledge to manage the home so residents and staff needs are supported There are systems in place so that the quality of the service can continue to be improved with reference to service users needs and comments EVIDENCE: Joan White is the Registered Manager. She has been in post for 3 years and holds an NVQ qualification in Management. She continues to update her skills and has more recently completed an update in medication and dementia care. Joan was not available on the inspection as she was on holiday. Staff felt that they received good support from her and that she was approachable. The
Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 24 senior staff present were, for the most part able to access the information asked for and the systems in place generally supported the staff in the managers absence. The home undergoes an external audit on a yearly basis in order to monitor and improve quality. The manager has her own objectives displayed in the office and these are linked to both the audit and CSCI inspections. There are regular meetings with key staff to discuss the progress of the home. Resident and relative feedback is canvassed on a 6 monthly basis and the comments seen were very positive The various policies and procedures for the home are reviewed on a regular basis and staff reported that the manager communicates any change in policy on a regular basis through posting them on the staff room notice board and all staff are expected to read and sign. New staff are given a staff handbook with key policies. Staff were clear about the policy in the home for managing residents monies and safekeeping of valuables and were able to explain this. Relatives said that any finance issues were addressed promptly. Health and Safety records are maintained. Policies and procedures as well as maintenance certificates such as Gas safety and Electrical safety were seen. Accident records were discussed and a recent example of an accident record inspected. A resident had had a fall and relatives had been informed. A decision had been made to not refer for medical opinion based on observations of the resident as being mobile and not experiencing any discomfort or pain. The record however only showed ‘no apparent injury’ and the importance of recording more detail was discussed. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 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 Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 26 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. 2. Standard OP7 OP25 Regulation 15 23 Requirement Care plans must contain all care needs and detail particular interventions in greater detail. The hot water temperatures in baths and showers must be maintained at a safe temperature. Thermostatic valves must be set at 43C and regularly checked. Timescale for action 01/08/06 22/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP7 OP9 Good Practice Recommendations The Service User Guide for the home should be available at all times. The evaluations of the care plan should record discussion of residents progress set against the aims / goals of the care plan Residents on PRN medication should be referenced in the care plan with agreed guidelines for administration recorded.
DS0000051273.V301335.R02.S.doc Version 5.2 Page 27 Hope Cottage 4 5 6 7 OP9 OP12 OP18 OP19 8 9 OP28 OP38 The resident discussed who is on PRN medication should be further assessed. The programme of activities for residents can be further developed with reference to current literature and good practice. The programme of staff attending for training sessions on Vulnerable adults [POVA] should be completed. The environment can continue to be developed with reference to dementia care practice. The placing of appropriate signs / photographs on residents bedroom doors to aid orientation was discussed. A minimum of 50 of care staff should be trained to NVQ level 2. Accident reports should contain a record of the observations made by staff following accidents so that decision making can be properly informed. Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Hope Cottage DS0000051273.V301335.R02.S.doc Version 5.2 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. 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!
