Inspection on 05/12/05 for Hungerford House

This inspection was carried out on 5th December 2005.

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

Hungerford House 15/01/07

Hungerford House 29/06/05

Hungerford House 12/01/05

Hungerford House 26/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Hungerford House Beechfield Road Corsham Wiltshire SN13 9DR Lead Inspector Ms Sally Walker Unannounced Inspection 09:30a 5 December 2005 th 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 Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 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. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hungerford House Address Beechfield Road Corsham Wiltshire SN13 9DR 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) 01249 712107 The Orders Of St John Care Trust Diane Eileen Gooch Care Home 48 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (25) Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May from time to time admit persons between the ages of 60 and 65 Date of last inspection 27th June & 14th July 2005 Brief Description of the Service: The building was originally purpose built by the local authority in the 1970’s. The Orders of St John Care Trust took over the care provision on 1st October 2000. There are 48 single bedrooms all to the ground floor. The home offers 3 respite care beds. The home is divided into three units namely: Roberts, Lilley and Hall. These units have their own sitting room, small kitchen area, bathrooms and toilets. Two of the units now eat together in one dining room. The building is partway through an extensive refurbishment and improvement plan to the physical environment. There is a separate day service for up to 25 people; with 5 places offered to people with dementia. The care staffing rota provided for one care leader and 5 care staff during the mornings, 4 care staff and a care leader during the afternoons and evenings and 3 waking night staff. The home also employs cooks, housekeepers, a laundry person and a handyman. Mrs Diane Gooch has managed the home since February 2005. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.30am and 4.15pm. Mrs Gooch was present during the inspection but was supporting staff as 2 care leaders were on sick leave that day. 7 residents, 2 visitors and a relative were spoken with. The care records and staff training records were inspected and a tour was made of the accommodation. What the service does well: What has improved since the last inspection? Mrs Gooch has put much effort into improving the systems for recording, upgrading the environment and developing the staff team. The organisation has adopted an assessment document co-produced by Mrs Gooch. This enables a more comprehensive pre-admission process which informs the care plans. Initial care plans were in place on the day that new residents were admitted. Care plans were significantly more detailed but some work is to be done to keep them up to date. Monitoring of medical conditions was more thorough. Staff had received training in tissue viability and good progress had been made in starting to assess each resident as to their risk of developing pressure sores. A part time activities post has improved the range of activities offered to residents. Staff can now concentrate on care provision although they are still involved in some activities. Residents did not say that there was nothing to do or that they did not go out enough as they had told the inspector at previous inspections. Regular residents meetings allow residents to discuss any issue of concern. They said they would also talk to their keyworker or Mrs Gooch who was well known to them. A programme of regular supervision for all staff was in place. All staff had been trained in mental health issues and dementia with an ongoing programme in place for dementia. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Having adopted a draft pre-admission assessment document, potential residents can now be sure that the home will endeavour to know as much detail as possible about them, their care and medical history, how they would like to have their needs met and what interests them. EVIDENCE: The home has adopted the draft pre-admission assessment document, developed by Mrs Gooch and 3 other managers. Initial care plans are now more detailed, with comprehensive information for staff, the pre-admission document allows the assessor to gain as much knowledge as possible about he potential resident and the social history compliments the care plan. One of the findings of a recent complaint investigation was that a pre-admission assessment was not in place. Previous documentation did not ask for sufficient information about needs, particularly for those potential residents with dementia. It was clear from the records of those residents who were recently admitted using this assessment document, that the care plan provides a better picture of how the care was provided. Mrs Gooch reported that care managers cannot place residents without an up to date assessment being provided. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 9 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 Care plans have significantly improved but without continued review as needs change, they are not up to date and accurate. Residents have good access to healthcare professionals. Staff respected residents. Relative’s experience was that the home were respectful and sensitive the end of the resident’s life. EVIDENCE: The requirement that care plans were kept under review and updated as necessary was in good progress. A recent complaint investigation identified that care plans and risk assessments were updated as events occurred. Mrs Gooch had made great efforts to ensure that the care plans and risk assessments were more comprehensive. She had carried out most of this work herself. Mrs Gooch was insistent that staff hold comprehensive handovers so that all are aware of changes and could update the care plans. However, it was noted that some recent events did not prompt an update of the care plan. One resident who was in their bedroom did not have their call bell within reach; although it was reported that they would be unable to comprehend how to use it, there was no statement in their care plan or risk assessment. Another resident who said they did not sleep in their bed did not have their sleeping arrangements defined in their care plan or risk assessment. There were 2 examples of residents notes recording that they had a sore and Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 10 the other had their leg re-dressed but no detail in the care plan or guidance on its treatment. There was mention that the district nurse was visiting. As a matter of good practice it was noted that all of those residents seen were well groomed with clean glasses, fingernails, hair, teeth, matching clothing and no facial hair. Staff clearly put much effort into ensuring residents have good attention to their personal care. Staff had good relationships with residents and were respectful in all their interactions with residents. All personal care was carried out behind closed doors. Residents had good access to healthcare professionals with written evidence of prompt referral to the relevant person when concerns were noted. Residents were regularly weighed and any significant loss referred to the GP. Those residents with diabetes had their condition regularly monitored and there was clear instruction to staff on what action to take dependent on the results of blood sugar monitoring. The requirement that all care staff received training in tissue viability in order to assist them in completing assessments of residents’ risk of developing pressure sores; to include nutritional assessments had been actioned. The assessments now need to be completed for all residents. Some residents’ risk had been assessed and pressure-relieving equipment was in place. It was noted that one resident who administered their own medication was storing the containers on display in their room. The inspector advised them that it should be stored in the locked facility provided in order to reduce the risk of it being taken by anyone else. One of the relatives of a resident who had recently died talked about the care and support their relative had received. They said that the staff were excellent in the constant care that they had provided. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 The appointment of an activities person has improved this provision for residents. Residents retained contact with families and friends. Residents said they enjoyed the quality of the food and met to discuss the menus. Nutritional monitoring was in place. EVIDENCE: Not all of the residents were up; one of those residents still in bed having their breakfast had reference in their care plan and daily report that they preferred to stay in bed later. The home has employed a part time activities person for 20 hours a week. Although it is not many hours, this appointment has had significant impact on the quality of life for residents. Activities preferences were included in the care plans. The activities programme was extensive with one to one and group activities mornings and afternoons except Sundays. There was a plan for the Christmas activities about to be published. A newsletter was being produced. A group of residents were doing stretching exercises to music; they were then read extracts from the day’s newspaper which prompted a discussion about Christmas. None of the residents spoken with said there was nothing to do or that they did not go out as had happened in the past. Mrs Gooch reported that trips out had been organised but residents were reluctant to go out when the time came. There were many events being held with other homes in the organisation but residents were reluctant to go to them too. Only one resident Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 12 said that staff were too busy with no time to talk to them. Most residents were clearly more stimulated. The menu displayed on the notice board, showed a good range of traditional meals suited to the tastes of older people. The choice meals had been stopped but the minutes of the residents meetings displayed nearby showed that this was discussed and agreed with the residents, the reason being that there were 2 cook vacancies and it was decided to offer one meal and a salad as some of the meals would be prepared by agency cooks. There was a cooked breakfast on 2 mornings, soup at lunchtime and on one menu fish and chips from the chip shop. Residents said they enjoyed the quality and range of meals provided. One resident’s daily report showed that they had told staff in the middle of the night that they were hungry and had been provided with something to eat. It was clear from talking to staff and Mrs Gooch that they had a good understanding of good nutrition especially with people with dementia. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Residents and their relatives can now know that they can comment on any dissatisfaction with the service and know that they will be listened to by the home. The complaints procedure is more accessible to residents. The organisation is poor at responding to complainants. EVIDENCE: The recommendation that consideration should be given to any potential barriers to some residents being able to openly express dissatisfaction with any aspect of the service has been resolved. There was always a complaint procedure in place, however there were some issues relating to the time before Mrs Gooch was running the home. The issues were a symptom of the home having no permanently employed manager. Some residents and their relatives felt there was no one to talk to about some problems they were experiencing. Now that Mrs Gooch has instigated regular residents meetings, most of the residents were discussing issues, as noted in the minutes posted around the home. Discussions with residents showed that there was now a culture where residents could openly discuss issues; residents said they would talk to their keyworker or directly to Mrs Gooch who was well known to them. Two visitors and a relative commented very positively on the improvements in the environment, the care, the atmosphere, activities and social events since Mrs Gooch had come to post. Since the last inspection a complaint referred to the organisation for investigation through its own complaints procedure, was poorly investigated with poor response to the complainant. Requirements were made and an action plan is now in place. The Commission has met with the organisation to Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 14 discuss concerns regarding their investigation of complaints and it was agreed that training would be sought. All of the staff save those newly appointed had completed training in the local Vulnerable Adults procedure and Mrs Gooch said they had all been provided with a copy of the document entitled “No Secrets in Swindon and Wiltshire”. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Much of the physical environment has been significantly improved in line with the organisation’s 5 year refurbishment plan. Other items identified by Mrs Gooch and not in the original plan could compromise residents’ safety if not addressed. The allocation of cleaning and housekeeping staffing levels does not allow some areas of the building to be kept cleaned to infection control standards. EVIDENCE: The requirement that a plan must be submitted showing the timescales for the refurbishment of the remainder of the building was in progress. Mrs Gooch had obtained quotes for much of the work and was dependent on confirmation from the organisation for the work to go ahead. She had identified other areas, not on the original plan, which were in need of attention, namely the safety of the exit doors following a complaint and some of the carpets. One carpet which was relatively newly laid in one of the dining rooms and outside one of the unit kitchens was badly stained. One of the sitting rooms had a strong smell of urine. Mrs Gooch said she had got a contractor to deep clean the carpets but the quality was not sufficiently robust for the amount of constant use. She went on to say that there was a housekeeping vacancy that Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 16 was advertised with 5 extra hours added to the post. Night staff did some of the cleaning. A contractor was measuring for quotes for new carpets to the other areas with very old and discoloured carpets on the day of the inspection. Mrs Gooch said that she was employing a second part time handyman to initiate a project to re-decorating programme, beginning with the bedrooms. The safety of the exit doors had been reviewed and Mrs Gooch was awaiting confirmation from the Wiltshire Fire Brigade for the installation of locks to the front door. Mrs Gooch also reported that some of the fire doors needed replacing and was awaiting confirmation of budget from the organisation. The last phase of replacement electrical wiring was in completion in one of the units. A budget had been set aside for refurbishment of the kitchenettes in each of the units. These kitchen areas were very old the surfaces deteriorated making them very difficult to keep looking clean. Mrs Gooch had identified 3 windows in need of replacement. She said she was meeting with a surveyor from the organisation later that week to discuss those issues she had identified which did not form part of the initial 5 year refurbishment plan and were now a priority. The requirement that those areas of the home that are not always visible are cleaned to infection control standards was in good progress. However there were some hoist seats and toilet grab rails in need of attention to remove brown deposits and dried brown drip marks. The allocation of cleaning staff time only allows cleaning during the mornings at other times, care staff are expected to carry out these duties. Given that all staff had been trained in infection control recently, the cleaning issue is one of cleaning staff allocation. It was noted that residents’ bedrooms were much cleaner. There was also plentiful supplies of protective clothing and gloves. One of the residents said they were not allowed in the laundry but could hand wash some small items of clothing. One of the care staff was distributing laundry as the laundry person was sick. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 17 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 & 30 Staff were skilled and well trained. Care staff are expected to carry out some domestic duties, as the allocation of housekeeping staff is mainly during the mornings during the week. Many of the requirements of this report are a symptom not insufficient staffing levels. Staff had good relationships with residents and committed to providing good quality care as a priority. EVIDENCE: The requirement that consideration was given to the allocation of staffing hours had not been actioned. The organisation submitted a proposal to increase the establishment hours in May 2005 and 7 months later there has been little increase; a laundry person during weekday mornings and a part time activities person. A recent complaint investigation identified poor staffing levels for adequate supervision of residents. The appointment of a care leader with primary responsibility for running the dementia unit had not meant that their care leader’s post had been filled. Mrs Gooch had tried to manage the demands on staff during mealtimes; including giving medication, by amalgamation 2 of the unit’s dining rooms. Whilst this is not satisfactory, it allows residents to have at least 2 care staff during this time to provide this support and one to give medication. Much of the administrative and management tasks normally carried out by care leaders, for example, review and revision of the care plans and risk assessments, had been done by Mrs Gooch in order to show staff what is expected. The inspector is of the view that much of the ongoing need to review and revise the care plans is due to staff not having sufficient time exclusive of the care rota. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 18 On the morning of the inspection 2 care leaders had called in sick. Mrs Gooch explained that she had covered the 6 staff required with a bank staff, one of the staff normally working in the day service and an agency staff, however she was leading the shift. Mrs Gooch had also worked the waking night shift to induct a new member of staff and ensure that a resident who was very poorly had someone with them. The requirement that a programme of regular staff supervision was in place so that staff received a minimum of 6 sessions a year had been actioned with a programme displayed in the care office. The requirement that a programme of staff training in mental health was in place to meet the needs of the 4 residents registered in this category as in good progress. The community psychiatric nurse had provided comprehensive training for the majority of staff and Mrs Gooch had requested a further training programme from the organisation as she had difficulty in securing further training from the community psychiatric nurse and other mental health sources. She had also requested that mental health training was included in the standard induction programme. The training records showed that there had been a significant improvement in the amount of relevant training offered to staff. The majority of staff had recently undertaken training in moving and handling and those who had not updated this training were booked for another course. The majority of staff had trained in infection control and tissue viability training from the local district nurse. Three staff were attending first aid training that day. A programme of training certificated by the Alzheimers Society was planned with attendees having to complete a workbook. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 19 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 & 37 Mrs Gooch has done much to develop the home and the staff team after a long period of time without a manager. She is clear about how she wants the service to develop further. Record keeping has improved. EVIDENCE: Mrs Gooch continues to develop the systems and implement good care practices. Staff have responded well and work as a team. Mrs Gooch has a clear picture of what still needs to be achieved and how. The requirement that all records were kept up to date and were accurate was in very good progress. Great improvements had been made in completing all of the forms and ensuring that current care needs were identified. However, The recommendation that consideration was given to adopting the draft preadmission assessment document as it was more comprehensive than that used at the time has been actioned. Mrs Gooch was involved in its development as previous documents did not ask for sufficient information about needs, Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 20 particularly for those potential residents with dementia. It was clear from the records of those residents who were recently admitted that more information was going into the initial care plan. Mrs Gooch said that she was due to present her budget to the organisation that month. A number of urgent items were to be presented and it is expected that they will take priority. Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 3 X Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 22 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(2)(b) &(c) Requirement Timescale for action 05/12/05 2 OP27 18(1)(a) 3 OP21OP19 23(2)(b) &(d) The person registered must ensure that care plans are kept under review and updated as necessary. (Good progress continues to be made). The person registered must 05/12/05 consider the allocation of staffing hours to ensure that residents care, social and environmental needs are met, with full provision of care staff, laundry staff and cleaning staff. This should also include administrative and management tasks which staff carry out exclusive to care. (A proposal was submitted by the organisation in May 2005 but there has been little progress in its implementation). 31/01/06 The person registered must submit a plan showing the timescales for the refurbishment of the remaining part of the building. (Progress is being made in the refurbishments. Mrs Gooch was awaiting confirmation from the organisation for completion of further safety issues and redecoration). DS0000028283.V261547.R01.S.doc Version 5.0 Hungerford House Page 23 4 OP26 23(2)(d) 5 OP9 13(2) &13(4)(c) 6 OP16 10(1) &22(3) The person registered must ensure that those areas of the home that are not always visible are cleaned to infection control standards. (Progress had been made, but some areas still needed attention. Cleaning staff only work during the morning and care staff cannot provide the care needed if they are also expected to carry out cleaning and laundry duties at other times). The person registered must ensure that if residents are administering their own medication that they are made aware of the need to keep that medication locked in the facility provided for the protection of other residents. The registered provider and the registered manager must ensure that any complaint made under the complaints procedure is fully investigated using the organisation’s procedure: Management of Complaints. 05/12/05 05/12/05 05/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Hungerford House DS0000028283.V261547.R01.S.doc Version 5.0 Page 25 - 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. 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