Inspection on 01/06/05 for Hopton Court

This inspection was carried out on 1st June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hopton Court 08/05/07

Hopton Court 15/08/06

Hopton Court 27/10/05

Hopton Court 07/12/04

Hopton Court 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Hopton Court Hopton Mews Armley Leeds LS12 3HT Lead Inspector Sue Dunn Unannounmced 1 June 2005 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. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hopton Court Address Hopton Mews, Armley, Leeds, West Yorkshire, LS12 3HT 0113 263 2488 0113 2632509 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) Highfield Care Management Limited Mrs Elaine Parker Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/12/05 Brief Description of the Service: Hopton Court is a 40 bedded home which provides care for older people with dementia. The home was purpose built as a residential home for older people, though not architect designed specifically for people with dementia. The building was constructed with new environmental standards in mind so all rooms exceed the minimum standard on size and all have en suite toilet and hand washing facilities. Built on two floors, there is access to the first floor by passenger lift. Each floor operates as a separate unit with food and laundry being provided from a central area on the ground floor. A garden area to the rear of the building has been developed to provide a secure outdoor sitting area for service users, and which allows them the freedom to wander outside in safety.The home is situated in the Armley area of Leeds within walking distance of the main shopping area, a small park, two pubs, a hairdresser and a post office. Because of the vulnerability of the residents, restrictions, in the form of digital locks (linked in to the fire alarm system) prevent residents walking freely around all areas of the home. The front door can only be opened by staff for the same reason. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was unannounced, was undertaken by one inspector. The inspection started at 8.35am and finished at 4.30pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. The deputy who has only recently been promoted into the post assisted with the inspection as the manager was on leave. The home has been without a deputy manager for most of the past year. The inspector spoke to residents, a visitor, staff members, and the deputy manager. Records were inspected, including resident’s care plans and daily occurrence sheets, staff recruitment and training files, and service records. What the service does well: What has improved since the last inspection? Menu boards were kept up to date and some efforts made to provide signing which assisted people to find their way around the home. The home has a deputy manager and an administrator to support the manager. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 6 What they could do better: This was a disappointing inspection as little was seen which distinguished what ‘specialist care’ the home provided from that given by any other home, there had been no progress on staff training and customs and practices had developed which were not in the best interests of the residents. Contracts need updating to include the number of the room each person is to occupy. Pre admission assessments should provide enough detail for the home to identify how to prepare to meet the needs of the assessed person when they are admitted and as an ongoing plan for their care and well being. More could be done to assist people during the early days of admission and reduce anxieties experienced by anyone in a strange place. There must be sufficient staff at all times to meet the needs of all residents. Accidents must be monitored and if necessary underpin a risk management plan. Accident records must meet data protection requirements. Care plans must provide information which is relevant and explain how and why care is in the interests of the residents, whose wishes must always be considered. Staff should record their own part in any care given to provide a log of progress. Staff must understand what medication they are giving to people and why and follow safe recording procedures. The homes routines and practices must always consider the needs of residents first and not be for the convenience of staff. Staff should be able to sit in comfort whilst assisting people at mealtimes and use this time as a social occasion. There must be evidence to show that people do not go for long periods of time without food and drinks. There must be an equal division of management and supervision time throughout the home. Staff who take on ‘senior care’ roles must have the training knowledge and skills to carry out this task in the best interests and safety of the residents and be appropriately supervised. Staff should take more responsibility for helping people to make their rooms a place of familiarity and comfort. Staff must commence training in adult protection, understanding medication, how to understand the needs of people with dementia and NVQ as a matter of urgency. The home has had since the introduction of the Care Standards Act 2000 to make provision for this and has made no progress. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 7 The manager must inspect recruitment and selection information more diligently and keep appropriate records of the selection process. The manager must have a qualification and training which reflects her role and responsibilities and allows her to discharge her responsibilities fully. The home has been aware of the standard for this since 2000 and has made no progress. All these matters have implications for the Health and Safety of people who live and work in the home. 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. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 8 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 Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 9 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) 2,3,4,5 The contracts of the terms and conditions of occupancy do not give residents information about the room they are to occupy. This could lead to residents being moved to different rooms without consultation. The home had not obtained satisfactory pre admission information and had not carried out their own assessment of need therefore could not give assurances that they could meet the needs of a new admission. There was no guidance or preparation to make the admission of a new resident a helpful and pleasant experience and reduce levels of anxiety and confusion. EVIDENCE: Copies of the contracts were seen in the administrative office. It was evident that these were being changed due to the change of ownership of the home. The contracts do not include the number of the room to be occupied as required in the standards. Assessments are held on a folder for people on the waiting list for admission. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 10 The information in these was limited and accompanied by an assessment document to assess cognitive skills which was recommended at the last inspection. This had been completed simply by circling the numbers associated with each function. No attempt had been made by the assessor to ‘humanise’ the information with explanatory comments. No pre admission assessment could be found for a person admitted to the home on the day of the inspection. A faxed copy of the referral had been received from the hospital on 22.04.05, six weeks before admission, which only gave information about the type of home needed and the needs of the family. There was no information about who had made a diagnosis of dementia or what type of dementia, nothing to show what skills and abilities were retained and no past history or information about significant people and events in the person’s life. There was no record to say if a pre admission visit had taken place or by whom. ( A visitor of a self funding resident confirmed that she and her family had visited the home before admission.) Staff did not use any systems for working more closely with the person on the day of admission find out more about him, explain how to find his way about and reduce any anxiety and disorientation. The person was left to his own devices and staff intervened when he started to wander. Though cheerful he appeared bewildered. The same was found in the care file of a person who had been in the home since 2004. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,11 As care needs increase each unit must have sufficient staff to meet the range of care needs of each resident. This has not been the case and could be a contributory factor in the high number of falls. Staff need more supervision and monitoring by experienced staff if the care plans are to provide a relevant and meaningful guide which recognises the individuality of each person’s needs. Accident records do not meet data protection guidelines and are not being used to develop risk management plans to reduce the likelihood of falls. The handling and recording of medication is unsatisfactory, placing residents and staff at risk. EVIDENCE: The care files of four people were inspected including the person admitted the same day. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 12 The volume of care planning paperwork is extensive but some of the information is basic. An example of this in the personal care stated ‘likes to look clean and tidy’ but gave no information regarding personal preferences for clothing, jewellery, makeup. A skin tear was well described and showed the district nurse was visiting but there was no indication when or how this may have occurred. One file had a very good pen picture and past history, another gave no information which staff could use for the well being of the person. A review with a relative three months after admission did nothing to remedy this gap. Several risk assessment action plans were undated therefore it was difficult to know if and when they had been reviewed. Accident recording was satisfactory but did not meet data protection as information about each person was recorded on the back of the page containing information about the previous person. There were a high number of falls. A person who had been in the home for three weeks had two falls but there was no evidence of a risk management plan and nothing to indicate the manager was regularly auditing the system and discussing how the number of falls may be reduced. Staff stated that medication training, which they acknowledged was needed, has been cancelled three times. The staff handling medication did not know what the medication was for, medication records were not being signed when the medication was given and the inspector was informed that there had been occasions when staff had signed off the medication sheets for medication to be given after the person had gone off duty. It was explained that witness signatures for controlled drugs are signed by day staff who check the remaining balance of medication as part of the handover. This does not confirm the medication has been given to the person it is intended for and leaves both staff and residents vulnerable. At the request of a family the home has agreed to continue to care for a resident who is becoming increasingly frail. This is in addition to 19 other residents on the unit, two of whom require two staff for assistance. The rotas and discussion with staff revealed that there are occasions when only two care staff have been working on the unit. Staff admitted there are times when only basic care needs can be met. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Staff showed a genuine fondness for the people in their care and were trying to provide a good level of care. However, routines, customs and practices have developed for the benefit of staff rather than in consultation with the residents and go unchallenged. EVIDENCE: At the time of arrival at 8.35am all the residents on the ground floor were up and dressed, breakfast was over and the dining room tables had been cleared. A member of staff said that the night staff start getting people out of bed at 6.30-7am in the morning, a practice which had been going on when she started working in the home and had not been questioned. Several people were asleep in chairs in the lounges during the morning Another member of staff raised concerns that staff have been instructed by senior care staff to change residents into their night clothes early in the evening and put them to bed ‘to help the night staff’. This was done without consultation with residents or their sleep patterns and led, she felt, to people getting up during the night and wandering. Staff were able to talk about the way they worked with different residents but none of this was recorded in the care plans as a guide for other members of the team. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 14 Senior care staff who were on leave were thought to be ‘dealing with’ other professionals for advice on care matters. There was no written evidence of the action taken therefore other staff were unaware of progress towards having residents needs met. Staff admitted that they had limited skills and little time for activities whilst the activity coordinator was on maternity leave. There was nothing in the care plans to show that past lifestyles and interests had been used to develop plans of care for personalised activities. However, on the day of the inspection staff were working with a small group of people who were chatting whilst using the foot spas. A visitor said she had ‘no cause for complaint’. She described the home as always clean and the staff pleasant and affectionate. A relative had provided an album of family photographs which staff talked through with her mother if she became upset, an activity which had a calming effect. Some bedroom doors had a picture of the occupant of the room and their name in large print to help people to identify their own room. This had not been done as a memory aid for the newly admitted resident. The midday meal was observed and sampled in the dining room on the first floor as this area is furthest from the kitchen. The menu for the day was shown on the board in the dining room, the meal offered two choices and was hot and tasty. A low sugar dessert had been specially baked for people with diabetes. There were insufficient chairs in the dining room for staff to sit whilst assisting people with their eating consequently they were having to crouch uncomfortably on the floor. There was little conversation or interaction with people during the course of the meal. Tea was served at 4.30 pm to fit in with the hours worked by the catering staff. The person doing the cooking acknowledged that this leaves a long gap before the next meal. Food is left for the night staff to give with the drinks at 7pm and 9pm but this may be limited to biscuits. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a complaints procedure. However an earlier complaint investigated by the organisation remained a cause of staff concern. The management of the first floor is left to the senior carers on duty on that floor without the benefit of training to support the role. Without Adult Protection training staff are ill equipped to recognise and deal with any matters which may arise. EVIDENCE: The organisation has in the past carried out a full investigation of complaints brought to their attention. There was a lack of confidence that issues brought to the attention of senior managers would remain confidential. There was a feeling that managers did not spend time working on the first floor and observing practices. This was raised in the past as part of an anonymous complaint and was unsubstantiated. However, it still appears to be a matter for concern. The acting senior care worker was left in sole charge of the first floor during the course of the inspection as the deputy was carrying out duties on the ground floor. The staff, including the deputy who was responsible for the home in the manager’s absence said they had not received training in adult protection and working with vulnerable adults. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,24,26 Overall the home is clean and well maintained. Staff should do more to help residents who have no family support make their rooms more comfortable and individualised. EVIDENCE: The retired general maintenance man was doing all the routine safety checks on the home in the absence of the regular maintenance person. Overall the home was clean with furnishings and fittings of a good standard and chairs offering different heights of seating. Odour control was satisfactory with the exception of an unpleasant smell of stale cigarettes in the office and the odour on the first floor from a recent ‘accident’. The cleaner thought that the odour control products were out of stock, but these were found to be available. One bedroom was very well appointed with personal possessions and photographs, which left the resident in no doubt which was her room. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 17 Another however only had the basic furniture supplied by the home and gave no indication of the personality and achievements of the person who had been occupying the room for almost a year. A brief conversation with the resident indicated her awareness of quality clothing. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27,29,30 Staff show they care for residents and work hard to try to offer care to the best of their ability. However, without guidance and training from experienced managers and trainers staff tend to follow the lead of existing staff, which may not necessarily be in the best interests of the residents. People are aware of areas of care which could be improved but lack the power and initiative to make changes. There have been occasions staffing numbers in parts of the home have fallen below an acceptable level for the needs of the residents. Staff training has fallen badly behind with staff only receiving the basics of the knowledge from existing staff. This lack of training can potentially place staff and residents at risk. There has been no progress made towards achieving the ratio of staff with NVQ as set by the standards. This is unacceptable given the length of time the home has had to meet the timescales. The home has not provided evidence in staff files to give assurances that the recruitment and selection process is sufficiently diligent. EVIDENCE: Staff said that there had been occasions when care workers had taken sick leave at short notice leaving only two staff working on the first floor. The rotas and the deputy confirmed this. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 19 There were concerns that there were at least three people on the first floor who needed feeding and two staff to assist with their personal care needs. It was said that each floor operated as a separate unit therefore staff from the ground floor did not move between floors to give assistance. The CSCI has not been notified how the care will be given when all attempts to cover staff shortfalls have failed. The plans for staff training looked very promising at the time of the last inspection but other than in house mandatory training provided by one of the senior care workers there has been no progress made since then. The only staff with NVQ were said to have already achieved the award before joining the home. Staff had not had any formal training in dementia care or adult protection, other than the basics during induction training. Dates had been booked for medication training but this had not taken place. Staff who were administering medication admitted they did not know what the medication they were giving was for . Staff said they wished to start the NVQ award and felt that nothing had been done. One person said whenever enquiries were made about NVQ the response was ‘It is being sorted out’. A member of staff who had worked in the home since January 04 had not had any further training since joining the organisation. Examination of the recruitment and selection files for three staff showed that references had not been thoroughly checked. The home had only one reference for two of the people employed, one of which was from a family member. There was nothing in the interview notes to show that information given in the application forms had been discussed with the candidate. There was insufficient information on one application to allow a thorough check of past employment history. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 33,37,38 The home operates as two separate units which leads to a perception that there are differences in management input. There should be a balanced management presence on both floors to ensure that the home is run in the best interests of the residents. The manager has not met the timescale for achieving a qualification in management and the care of people with dementia which enables her to discharge her responsibilities fully. The deputy and staff must be given training at a level appropriate to their roles to help them to develop the knowledge and skills required to care for the residents. EVIDENCE: Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 21 The home has gone through an unsettled time without a deputy during the last year and some periods without an administrator. Changes taking place within the organisation have once again led to another line manager for the home. The manager has many years of practical experience in care but does not have an accepted management qualification or dementia training to a level which befits her role (The deadline for the management qualification was April 2005).There appears to have been no attempt by the organisation to help her to meet the standard. The manager was on leave at the time of the inspection but the deputy manager, who has recently been promoted into the post, assisted with the inspection in a calm and efficient manner. It was acknowledged that if she is to carry out the management role expected of her she requires training beyond simply shadowing the manager. Staff are disillusioned by assurances of training opportunities which have not taken place and feel that this is affecting staff morale. There are concerns that senior care workers from nursing home backgrounds are left to manage without any management supervision and this is leading to residents views and preferences being overlooked. The Health and Safety checks for the home are being carried out by the retired maintenance man who is providing cover for sickness. A brief inspection of a selection of records found the records up to date. Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 3 x STAFFING Standard No Score 27 2 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 2 x 2 x x 2 x x x 2 2 Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 23 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 OP4 Regulation 14 Requirement Carried forward - There must be evidence to show a pre admission assessment has been undertaken by the home which can demonstrate how the full range of needs will be met Carried forward - Information from any pre admission visit by the resident or their representative must be included in the assessment The contract each person has with the home must include the number of the room to be occupied Information in the care plans must be consistent and sufficiently detailed to guide staff on the individuality of each persons needs and preferences and progress The homes medication policies and procedures must be followed for the protection of residents, and staff suitably trained by an acredited person There must be sufficient staff on duty at all times to ensure the care needs of more physically dependant people do not compromise the care needs of Timescale for action By 31.08.05 2. OP5 14 By 31.08.05 3. OP2 5 By 31.08.05 By 31.08.05 4. OP7,OP12, OP14 13,15 5. OP9,OP38 13 By 31.07.05 6. OP11,OP27 ,OP38 12, By 31.07.05 Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 24 other residents 7. OP12,14 12 Routines and practices in the home must be in consultation with and for the benefit of residents The home must be managed in a way which ensures people are protected and complaints satisfactorily resolved The progamme of NVQ and other training by suitably qualified people must be started to equip staff with the knowledge and skills to care safely for residents The home must ensure the recruitment and selection procedures are rigorous enough for the protection of residents The manager must meet the standards applying to a registered manager By 31.07.05 By 31.08.05 By 31.08.05 8. OP16,OP18 13,22 9. OP27,OP38 18 10. OP29 18 By 31.07.05 By 31.03.06 11. OP31 10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP24 Good Practice Recommendations Staff should assist those people with little family support to personalise their rooms Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds, LS13 1HP 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 Hopton Court J52 S1467 Hopton Court V229703 310505 Stage 2.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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