CARE HOMES FOR OLDER PEOPLE
Hopes Green Care Centre 16 Brook Road Benfleet Essex SS7 5JA Lead Inspector
Carolyn Delaney Key Unannounced Inspection 11:00 12th 13th June 2006 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 Hopes Green Care Centre DS0000018097.V293253.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. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hopes Green Care Centre Address 16 Brook Road Benfleet Essex SS7 5JA 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) 01268 752327 01268 755518 the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Manager post vacant Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Personal care to be provided to no more than fifty service users over the age of 65 years. Total number of service users for whom personal care is to be provided shall not exceed 50. Date of last inspection Brief Description of the Service: Hopes Green Care Centre is a large home providing accommodation and personal care for up to fifty older people aged over 65 years of age who need assistance with personal care. The homes facilities include several communal lounge/dining areas and fifty single bedrooms all with ensuite facilities. The home is situated within easy walking distance of local shops and amenities, with Southend and Canvey Island main shopping centres a short car or train journey away. There are good bus and train links to the area. The garden enables service users to access a patio area and garden safely. There is ample car parking for visitors and the home has adequate wheelchair accessibility throughout. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a routine unannounced Key Inspection carried out between 11.00 and 18.00 on 12th & 13th June 2006. The lead inspector for the service Carolyn Delaney carried out the out the inspection. Records including assessments, care plans, daily care notes and risk assessment documents in respect of five people living at the home were examined. A number of ‘Have your say about….’ questionnaires were sent to the home prior to the inspection so as to obtain residents views. Six were returned. Nine residents and three relatives were spoken with during the inspection. The relatives of fourteen residents at the home and a number of healthcare professionals including district nurses and social workers were contacted by post so as to offer them the opportunity to make comments about the services provided by the home. At the time of completing the draft version of this report responses had not yet been received. Six responses were received prior to the report being published and comments have been incorporated into this version of the report. Six members of staff including the homes acting manager and the care manager were spoken with and a number of records including duty rota’s and staff recruitment files were examined. A tour of the premises was carried out and the serving of breakfast, lunch and evening meal was observed. All Key Standards as identified in the intended outcomes sections of this report have been inspected during this Key Inspection as they must be inspected at least once every twelve months. Where other standards have not been inspected on this occasion they will have been inspected at the previous inspections. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection?
There have been a number of improvements made since the last inspection. Senior staff ensure that people are only offered a place in the home after a detailed assessment of their care needs has been carried out. Staff now act so as to ensure that residents receive medicines which have been prescribed for them at the appropriate times, medicines are stored and disposed of in a safe manner and records are kept up to date. The number of complaints received about the home have reduced and complaints are dealt with appropriately and records kept up to date and accurate. It was positive to note that there were no unpleasant odours detected over the two days of the inspection and visitors to the home commented that the home generally smelt clean and fresh. Staff rotas have been improved and clearly evidence where and when staff work and the amount of off duty time they receive. Most of the residents who were spoken with felt that staffing levels at the home were adequate. Staff are now employed at the home in a robust and consistent manner with all of the necessary checks being carried out before they commence working at the home.
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 7 There have been changes in the management arrangements at the home and a care manager has been employed so as to support the homes general manager and to assist in improving the standard of care in the home. What they could do better:
Staff must ensure that where residents are of risk of injury from falls etc that information about the risks and how they can be minimised must be accurate and kept up to date in light of any changes to the level of risk such as when a person has a fall. Other information such as care plans and daily records must also be kept up to date so as to ensure that all staff working at the home have enough information to fully meet the needs of the people living at the home. Staff must take more care to ensure that people living at the home have their dignity and privacy protected and ensure that when carrying out personal care that attention is paid to residents nails etc. One relative commented that residents have not always had baths due to staff shortages. Another relative commented that on occasions there has only been two staff allocated per twenty-five residents. The people living in the home do not feel that there are enough activities provided for them by the home since the activities coordinator retired due to ill health. While the home have put in some temporary measure and have allocated 18 hours per week for activities this is not sufficient for the needs and wishes of the people living in the home. People living in the home are very dissatisfied with the food provided. Many complained about the monotony of the menu and the poor quality and taste of many of the meals. Meals could be made more palatable with the provision of condiments and sauces, which were not readily available. Residents in the lounge area did not have access to cold drinks throughout the day as jugs and glasses were noted to be left on a table in the middle of the room and residents did not have access to suitable tables. One relative commented that staff did not appear to have a good awareness of special diets. When staff who have not previously worked in a care setting must be given appropriate training and support when they are employed at the home and all staff must be regularly supervised and trained so as to ensure that they can met the needs of the people living in the home. One relative commented that staff could speak more slowly and clearly when assisting those residents who have hearing problems.
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 8 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. Hopes Green Care Centre DS0000018097.V293253.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 Hopes Green Care Centre DS0000018097.V293253.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, 3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the home is not kept up to date & accurate. The home ensures that people are only offered a place once an assessment of their care and welfare needs has been carried out so as to ensure that the home can meet these needs. The arrangements for contracting beds, which is currently in, place impacts upon resident’s choices of rooms at the home. EVIDENCE: Southern Cross Healthcare have taken over Hopes Green from the homes former owner Ashbourne Healthcare. At the time of this inspection new information had not been received by the home in respect of any changes in services etc as a result of the change of registered provider. However it was noted that information posted in various areas throughout the home included the name of a previous manager who has not worked at the
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 11 home for almost eighteen months. This could cause confusion to visitors to the home. Senior staff visit prospective residents and carry out a detailed assessment of their care, safety and welfare needs so as to determine that staff working at the home can meet these needs. Records in relation to these assessments were well written and detailed. Hopes Green has 22 contracted bed, which are purchased by social services. This contract with social services was negotiated with Ashbourne Healthcare. These beds are situated on the first floor (room numbers 31 – 50). Should these rooms become vacant they may not be used for other privately funded residents, which impacts upon choice for the people who move into the home. For example on the day of the inspection one resident and their family was spoken with. A room, which would be more suited to this person, needs and preferences had become available, however as it was a ‘contract’ bed this person cannot move in. The homes manager has no control over this situation. In general prospective residents do not, due to physical conditions or hospital placements etc, have the opportunity to visit the home prior to making a decision to move in. However this opportunity is offered and in the majority of cases relatives visits the home on behalf of the person to be accommodated. Both residents and relatives who were spoken with during the course of the inspection confirmed this. The ranges of fees for the home at the time of this inspection are: Social Services funded beds - £332.82 - £367.90. Private funding - £462.00 - £550.00 Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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 & 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information about residents care and safety needs is not consistently recorded in an accurate manner. Staff working at the home do not evidence that they consistently act so as to best protect residents from the risk of injury, act appropriately in the event of injury from falls etc. Staff ensure that residents receive medicines as prescribed for them and that medicines are stored & disposed of safely. Staff while generally observed to be caring and respectful they do not always ensure that residents personal care needs are met or that their dignity and privacy is maintained. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 13 EVIDENCE: The recording of information about the care & treatment including any risks to health & welfare, wishes and preferences of each individual is not maintained in a consistent manner. However staff who were spoken with were aware of residents needs. Some care plans were very well written and included details of the persons care needs, how these affected their daily lives and what care and treatment staff are to provide. However others were poorly written and contained information, which was not accurate. For example it was recorded for one individual that their appetite was poor and that staff should monitor food intake and monitor weight on a regular basis. However on assessing this person it was found that this person had a very good appetite and that due to their poor mobility they had not been weighed. Care plans were not generally reviewed appropriately and amended with information when there were changes to residents needs. For example three residents had recent falls. The care plans and risk assessments had not been updated in light of this and there was very little information recorded regarding the care and treatment provided including management of pain. An Immediate Requirement notice was issued in respect of the issues raised regarding the management of risks of falls and treatment of residents following falls / injury. Staff were observed on both days of the inspection to administer medicines to residents at the appropriate times. Records evidenced that staff receive, store and administer medicines safely and in accordance with the homes policies and procedures and current legislation. Generally staff were observed to be very caring when carrying out care and assisting residents. Both residents and their relatives who were spoken with during the inspection also confirmed this. However during the inspection one resident was observed in her bedroom using a commode with the door left open by staff and when this was brought to the attention of a member of staff their response was to say that they had just arrived on duty and to leave without closing the residents bedroom door. A number of residents were also noted to have dirty fingernails. One residents relative who responded to the postal survey commented that sometimes baths were not provided due to staff shortages and that staff were not always available to promote mobility. Residents wishes for arrangements following their death for example whether they would wish burial or cremation were recorded wherever they were happy to provide this information Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 14 Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does provide residents with a range of activities, which meets their needs and expectations. In general residents wishes and preferences are respected and residents are encouraged to maintain independence for as long as possible. Residents are unhappy with the food provided by the home. EVIDENCE: At the time of this inspection the homes activities coordinator had retired due to ill health. A member of care staff was providing some activities for residents, however there was only eighteen hours per week allocated for the provision of activities and those residents who were spoken with commented on the lack of activities available in recent weeks. The homes acting manager said that it was her intention to increase the hours for activities once the member of care staff involved agreed to act as activities coordinator on a full time basis.
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 16 All of the residents and relatives who were spoken with during the course of the two days inspection felt that residents wishes and preferences were taken into consideration and that they were supported to remain as independent as possible for as long as possible. All but one of the residents who were spoken with during the inspection complained that they were unhappy with the choice and quality of the food provided. Staff were seen to assist residents at mealtimes in an appropriate manner, however residents did not have condiments and sauces available to complement their meal. On the first day of the inspection staff was observed serving lunch to residents in the downstairs dining room. Staff asked residents if they wished to have gravy, however this was not the case when the serving of lunch in the dining room on the first floor was observed on the second day of the inspection. One residents relative who responded to the postal survey commented that staff did not appear to have an awareness of specialised diets. A number of small tables were available for residents to take beverages during the day. However there were insufficient numbers and on the first day of the inspection jugs of juice and drinking glasses were placed on a table in the middle of the lounge area. Residents did not have access to these and relied of staff to provide drinks, which there was little evidence of. Southern Cross are in the process of terminating the contract with the catering company who provide and cook food in the home. This will allow the homes manager to have more control over the choice and quality of food made available to the people who live at the home. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff practices do not generate any significant number of complaints and people living at the home feel confident that their complaints will be addressed in a satisfactory manner. Not all staff working at the home have up to date training in respect of the protection of vulnerable people, however there are measures in place to minimise the risks to people living at the home from abuse or harm. EVIDENCE: Records, which were kept in respect of complaints made to the home, were maintained in good order and evidenced that complaints were dealt with in accordance with the homes complaints policy and procedures. Residents and their relatives who were spoken with said that if they ever did have to make a complaint that they felt assured that the home would deal with any issues raised promptly. There was little evidence that staff practices generated an undue number of complaints. At the time of this inspection twenty-three of thirty-nine staff working at the home (59 ) had received ‘Resident Welfare’ training which covers aspects of protecting vulnerable people living at the home from abuse or harm. The home has a policy and procedure for reporting and dealing with any allegations of abuse or harm of people living at the home. Staff who were spoken with during
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 18 the course of the inspection could demonstrate what constitutes abuse of people including abuse by neglect and the homes acting manager has demonstrated a good awareness of adult protection issues and the correct procedures to follow in the event of any allegation of abuse or harm to people living at the home. One residents relative who responded to the postal survey commented that one carer had been a ‘little rough’ when handling her mother and that senior staff were aware of and looking into this. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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, 23 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Hopes Green, while providing a homely and safe environment is in need of some redecoration in areas. The home is maintained as far as possible free from unpleasant odours. EVIDENCE: Resident’s bedrooms, which were viewed with their permission, were noted to be comfortable and residents who were spoken with said that they were happy with the accommodation provided. Wherever it is possible bedrooms are redecorated when they become vacant as part of the homes maintenance plan. The communal areas were clean and free from odours. On both days of the inspection the weather was very warm and some doors and windows were open so as to allow good ventilation of the home.
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 20 Some areas of the home were observed to be in need of renewal and redecoration. For example some of the carpets in the lounge and hallways were worn and stained and skirting boards were scuffed. The home employs a dedicated team of domestic and cleaning staff and the home was clean and free from unpleasant odours during both days of the inspection. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are recruited in a consistent and robust manner. However the induction process is not sufficient for some staff who do not have prior experience of working in a care setting and staff training needs to be improved upon. EVIDENCE: The most recent staff duty rotas evidenced that staff are employed in sufficient numbers so as to meet the needs of the people living at the home. Residents and their relatives who were spoken with during the inspection commented that generally the staff were very kind and caring. Staff were for the most part observed to tend to residents needs promptly and in a sensitive manner throughout the inspection. However two of the six residents relatives who responded to the survey commented that there were often insufficient staff on duty. One relative commented that this was particularly so as weekends and another relative said that there are sometimes only two staff per twenty-five residents. Some staff duty rotas for the three months prior to the inspection were not maintained in a clear way so as to evidence that staff were deployed in appropriate numbers with sufficient off duty time. However the newly appointed care manager had implemented a new system for recording rotas, which was very clear and easy to decipher.
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 22 Staff recruitment files for three newly recruited members of staff were assessed. It was positive to note that no members of staff had commenced work at the home prior to the receipt of a satisfactory Criminal Records Bureau (CRB) disclosure and satisfactory references. All prospective staff members had been interviewed by the homes acting manager so as to further determine their suitability to work at the home. Records maintained in respect of the interview process could be more detailed in some cases so as to provide evidence in respect of the decision to employ the person at the home. The provision of induction and training for new staff recruited to work at the home was poorly evidenced and it was not clear that all staff upon commencing work had received mandatory training as part of the induction process. It was also noted that some staff had come to work at the home without any prior experience of working in a care home and it is judged that the induction provided is not sufficient for these members of staff. Between 56 and 77 of staff working at the home have received mandatory training updates. There was a training plan in place for other specialised training in respect of the needs of older people including care planning and managing illness associated with old age. Staff who were spoken with were aware of residents needs and the homes policies and procedures in respect of safe moving & handling, fire safety etc. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home has EVIDENCE: There have been a number of improvements in the level of service provided by the home since the last inspection. Notably the increase in regulatory requirements met has increased from 29 to 60 . Despite this, the concerns raised in respect of Health & Personal care and Daily Life & Social Activities standards have meant that the home is not providing a satisfactory level of service for the people who live there. At the time of the last inspection the acting manager had put forward two members of senior care staff to work together and cover the role of care
Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 24 manager. However this did not work and this has had an impact upon the level and rate of improvement at the home. A care manager has now been appointed so as to support the homes acting manager and a number of improvements been made in recent weeks. Records in respect of monies held for safekeeping on behalf of people living in the home were noted to be well maintained and regular checks are made so as to ensure that monies are kept safe and to minimise the risk of mishandling. At the time of the inspection only four senior members of care staff had received supervision and the acting manager was implementing a system for regular supervision of all staff working at the home. Throughout the inspection there were no health and safety issues observed in terms of the premises or equipment at the home. There was evidence that regular audits were carried out so as to ensure that gas, electrical and mechanical equipment and systems were maintained in safe working order. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 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 2 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered persons must ensure that plans in relation to the care and treatment required by people living at the home are clear, up to date and accurate and that they are evaluated and reviewed on a regular basis and when residents care needs or treatment changes. (Previous timescales following the last five inspections including timescale of 30/03/06 have not been met.) The registered persons must ensure that risks to resident’s health, safety and welfare are identified and managed so as to minimise the impact on residents. (Previous timescales following the last three inspections including the timescale of 30/03/06 have not been met.) 3. OP10 12(1) (a) (b) The registered persons must ensure that staff maintain & promote resident’s dignity and privacy
DS0000018097.V293253.R01.S.doc Timescale for action 30/07/06 2. OP8 13(4) (5) (6) 30/06/06 30/06/06 Hopes Green Care Centre Version 5.1 Page 27 4. OP12 16(2) (n) The registered persons must ensure that appropriate meaningful social; leisure and occupational activities are provided which meet the needs of residents living at the home. (Previous timescales following the last two inspections including the timescale of 30/03/06 have not been met.) 30/07/06 5. OP15 16(2) (i) The registered persons must ensure that residents are provided with nourishing meals which meet their dietary needs and so far as it is practicable their wishes and preferences. Residents must be provided with sufficient beverages and the means to access them. 30/07/06 6. OP28 18 7. OP30 18 The registered persons must 30/07/06 ensure that all newly recruited staff are inducted appropriately so as to ensure that the needs of people living at the home are met. The registered persons must 30/08/06 ensure that the all staff working at the home receive the training and support they require in order to meet the needs of the people living at the home. (Previous timescale of 30/03/06 following the last inspection of has not been met.) 8. OP36 18(2) All staff must receive regular supervision. 30/08/06 Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 28 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 OP1 OP9 Good Practice Recommendations Information posted about the home and made available to residents and visitors to the home should be kept up to date & accurate. A fridge should be provided for the storage of medicines. Hopes Green Care Centre DS0000018097.V293253.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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