Inspection on 07/08/06 for Ingham House Ltd

This inspection was carried out on 7th August 2006.

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

Ingham House Ltd 17/09/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ingham House Ltd Ingham House 10-12 Carlisle Road Eastbourne East Sussex BN20 7EJ Lead Inspector Gwyneth Bryant Unannounced Inspection 7th August 2006 08:15 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 Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ingham House Ltd Address Ingham House 10-12 Carlisle Road Eastbourne East Sussex BN20 7EJ 01323 734009 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) Ingham House Limited Vicki Sharman Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That a maximum number of residents to be accommodated must not exceed thirty-seven (37). That residents must be aged sixty-five (65) years or over on admission. That one named service user with a mental disorder under sixty-five (65) years of age to be accommodated. That one named service user with a dementia type illness to be accommodated. 1 November 2005 Date of last inspection Brief Description of the Service: Ingham House is registered to provide care and accommodation for up to thirty-seven older people. The home is close to Eastbourne town centre, shops and the seafront. It comprises two Victorian properties linked together on three floors and a rear extension. There are well maintained gardens to the front and rear of the property. Service user accommodation comprises thirty-five single bedrooms and one double bedroom. All bedrooms have at least a hand wash basin. There are two lounges, a large dining room and a conservatory. Level access to all floors is facilitated by the provision of stair lifts and a passenger lift in the extension. There are five communal bathrooms all of which are assisted. Grab and hand rails are provided as required. Both respite and long term care is provided. Nursing care is not provided. The service provides prospective residents with a copy of the homes brochure and an offer to visit in the first instance. A copy of the service users guide, the statement of purpose and a contract is supplied at the time of the pre-admission assessment process. The range of fees charged as from 1 April 2006 is from £366 to £595 in-house activities and toiletries are included in the fees. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Intermediate care is not provided. The homes email address is vicki@inghamhouse.co.uk. Currently the home does not have a website. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over seven hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect additional standards. There were thirty-five people in residence on the day of which five were spoken with. The Registered Manager, the Responsible Individual and one carer were also spoken with. In addition four relatives were contacted via telephone following the inspection. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Information was gathered from the pre-inspection information provided by the Registered Providers, in addition to surveys returned by 20 relatives and 17 residents. One of the Registered Providers assisted the residents to complete the surveys as part of the monthly monitoring visits. In the main the comments in the surveys were complimentary of the services provided at Ingham House, with several naming two particular senior carers as being especially helpful and caring. Comments included ‘always treated with kindness’; the home rates as number 1’; ‘ very happy with the organisation’; ‘can’t speak highly enough of everything that is being done’. Staffing levels was one area which was less positive with a number of surveys commenting that ‘baths are often deferred due to lack of staff’; ‘we visited all afternoon and did not see one member of staff’; ‘not always given tea when we visit’. All of the residents spoken with spoke highly of the quality of care given and the dedication of staff. Healthcare professionals were not engaged with on this occasion. What the service does well: What has improved since the last inspection? Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 6 Systems for the recording of medication has improved ensuring residents are not at risk. Work on the gardens and extension have been completed allowing residents to enjoy them during the warm weather. Residents are consulted on the contents of their care plan and systems for reducing the risk of tissue breakdown are now in place. These improvements have been carried out in respect of addressing the shortfalls identified at the last inspection. 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. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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 Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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): 1, 3 and 4. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to residents moving into the home which ensure that their needs can be met and they are provided with detailed information on services provided by the home. EVIDENCE: The Statement of Purpose and Residents Guide are regularly updated and contain all the information required so prospective residents are able to make an informed choice about where to live. Pre-admission documentation was viewed for recent admissions and it is evident that these documents are used effectively to ensure the home is able to meet the needs of prospective residents. At the time of admission information is sought from social and healthcare professionals to ensure all needs are clearly identified and planned for. Those residents spoken with could not recall a pre-admission visit but surveys returned showed that residents were aware that they or their relatives were provided with information and a contract prior to admission. Intermediate care is not provided. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning systems provide staff with clear direction as to how to meet all aspects of residents’ personal and health care needs but improvements need to be made in risk assessments. Residents are protected by satisfactory systems for the recording, handling and storing of medication. EVIDENCE: Five care plans were viewed and it was evident that pre-admission assessments are used to inform the care planning process. Care planning documents included information on meeting residents’ healthcare needs such as dental, hearing and eyesight checks and also provided clear direction to staff as to how residents daily care needs are to be met. Risk assessments had been carried out for all residents but some need to be expanded to include sufficient detail for the management of risks and the manager confirmed she will address this without delay. Throughout the inspection staff were noted to treat residents with care and respect and it was evident that good working relationships had been developed. Residents spoken with all said they felt well cared for and that staff are very kind. Comments in surveys included ‘care is always marvellous’; ‘extremely pleased with the high standard of care’; Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 10 ‘excellent care’; ‘absolutely marvellous’; ‘staff very supportive’ ‘the girls are so nice and work hard’. Of the less positive comments one was that they had a hearing problem so would prefer to have only carers whose first language is English and another said it would be nice if staff had time for just a chat. Two relatives spoken with said that staff used to let them know how their mother was but now they have to actively seek out the manager or a senior carer to get this information. However, all relatives spoken with said they felt the home provides good care for residents. Medication records and storage arrangements were viewed and systems remain effective. Medication administration charts were up to date, accurate and clear. Only staff who have been trained administer medication and this was confirmed by staff spoken with. Medication is stored in a locked cabinet in a locked room ensuring that unauthorised persons cannot access it. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place for residents to experience a lifestyle that matches their expectations, choice and preferences in respect of leisure activities and meals. EVIDENCE: There is a varied daily programme of activities for both the morning and afternoon. periods in which residents are encouraged to participate. These activities include skittles, bingo, quizzes, basketball, exercises and reminiscence. In addition there are shopping trips are provided three times a week in the homes’ minibus. Residents said they enjoyed the activities and one said they go out into the community with family and friends. The home also provides a buffet supper and games evening on the first Saturday of each month. On the day of the site visit, the inspector observed the musical bingo session. It was evident that residents enjoyed this activity however; one clearly stated that she could not read the card and staff did not respond to this. This was discussed with the manager who said that the home has larger print cards and staff should have provided them as required. She agreed to ensure all staff are reminded of those residents who have sight problems. Two residents spoken with said it would be nice if staff had ‘time for a chat as they are not keen on the group activities’. Comments in surveys included ‘I don’t join in the activities, I prefer my paper and my crossword’; Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 12 ‘I really enjoy the Saturday buffet and activity evening’; ‘I join in sometimes, when I feel like it’; ‘I would love a trip to the seaside’ ‘I enjoy all the activities’. One relative said her mother seems quite content but staff don’t seem to have time to encourage all residents to join in activities. Menus were provided as part of the pre-inspection information and show that meals are varied and nutritious. The cook is aware of residents’ likes and dislikes and these are recorded in care plans. Although the pre-inspection documentation did not show that an alternative lunchtime meal is routinely offered, the manager later confirmed that the menus given to residents does include an alternative each day. Residents spoken with all said the food is good and comments in surveys included ‘meals are always very good’; ‘they will always give me something else if I don’t like it’; ‘good meals’; ‘I enjoy my food’; ‘I would like more choice at supper’ ‘food is better in the week’. One residents’ care plan showed they are of a particular religious faith and the food preferences for this person had been identified and recorded. While the resident does not currently practice their religion, the home needs to ensure their care plan includes relevant information on their faith should the need arise. This was discussed with the manager who stated that the key worker is in the process of gathering information for inclusion in the documentation. Religious services are held in the home each month or residents go to local church services ensuring that religious needs are also met. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure with evidence that residents feel that their views are listened to and acted upon and residents are further protected by satisfactory adult protection systems. EVIDENCE: The complaints book was viewed and since the last inspection there has been one allegation of abuse, however this was a ‘one off’ incident between two residents and was dealt with appropriately. There has also been one complaint received by the CSCI in respect of a resident not being properly supervised and thus, the person left the home without staff knowledge and the home not communicating with relatives when a resident goes to hospital. During the investigation it was found that another resident, no longer living in the home, regularly left the home without staff being aware and on one occasion was returned to the home by the police. These incidents were investigated through the homes’ complaints procedure and as a result the home agreed to fit a warning bell to the front door so staff are alerted when someone leaves the home, however this had not been carried out at the time of the inspection. This was discussed with the manager who said that a pressure pad for the internal door would be useful in alerting staff if anyone comes into the home. The concerns in respect of the lack of supervision by staff of residents are addressed under Standard 27. In the surveys returned by residents two senior carers were singled out as being particularly kind and helpful. In addition survey comments stated that they would be happy to speak to the manager or one of the registered providers. Other comments in surveys included Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 14 ‘staff always ready to listen’; ‘would go to staff (to complain) or to cook if it was to do with meals’; ‘happy to speak to manager’; ‘ would go to the office – everyone is helpful when I go there’; ‘would speak to manager’. ‘ ‘If anyone was nasty to me I would report them’. Some of the less positive comments were: ‘staff don’t always listen’. Relatives contacted by telephone said: ‘sometimes I felt I was intruding if I went to the office or staff room/laundry areas’; ‘ I often had to wait for a day or two to speak to the right person and it was left to me to persist, no one offered to phone me with the information – I feel it would be an improvement if there was one person/place to whom people could go to with any queries, like a receptionist’. The staffing issue is addressed under Standard 27. Since the last inspection a rolling programme to ensure all staff receive training in adult protection has been implemented and staff were aware of adult protection procedures. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is generally good, with most areas homely, safe and comfortable for residents but could be improved if minor repairs were carried out promptly. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is generally good throughout. A number of minor shortfalls were identified such as tiles missing in bathrooms, a toilet that could not be flushed, offensive odours in two bedrooms and the hot pipes to the boiler being accessible to a resident. These shortfalls detract from the general attractiveness of the home. Residents’ bedrooms were well maintained and pleasingly decorated and it was evident that residents are able to bring in their own possessions in order to personalise their bedrooms. Comments in surveys included statements such as: Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 16 ‘Impressed with outstanding cleanliness’; ‘always very clean’; ‘the home standard is of the highest’; ‘never seen it dirty’ ‘its beautifully clean’. The laundry facilities are satisfactory and washing machines are able to wash clothes at temperatures that control the risk of infection. Not all staff have been trained in infection control and one was observed to be working in ways that may result in contamination. This was discussed with the manager who agreed to address the matter without delay. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care staffing levels need to be reviewed to ensure that residents’ needs are always appropriately met. The recruitment practice is not robust and does not provide sufficient safeguards for the protection of residents. All staff need to have sufficient training to ensure they are competent to do their jobs. EVIDENCE: Although both residents and relatives spoken with all commented on the quality of care given and the dedication of staff. There remained concern over low levels of staffing by three of the relatives, contacted by telephone, who felt that there were insufficient staff in the afternoons and at weekends. In addition three residents spoken with said that it would be nice if staff had time to sit and chat. These residents added that staff were lovely they always seem to be rushed. Staffing levels were an area that was of concern to both relatives and residents. Comments in surveys returned by relatives included: less staff at weekends’; ‘mornings are fine but in the afternoons its very hard to find someone to talk to’; ‘we used to get a cup of tea as soon as we arrived but not now’; ‘my relative’ bath has been deferred more than once due to lack of staff’; ‘we spent an afternoon visiting and didn’t see one member of staff’. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 18 The complaint received by the CSCI concerned residents who had left the home without staff being aware they had gone. While it is good practice to allow residents to enter and leave the home whenever they wish, there needs to be sufficient staff to supervise those residents who are at risk should they go out unaccompanied. These factors and the increased dependency of some residents indicate that staffing levels need to be reviewed without delay to ensure residents’ needs are fully met. Recruitment files for the last three staff to be recruited were viewed and it was found that only one had supplied all the required documentation prior to appointment. One did not complete the health declaration part of the application form and one other was providing personal care without a Criminal Records Bureau disclosure although a Protection of Vulnerable Adults First check had been carried out. This person was observed to be bathing a resident without supervision and when interviewed confirmed that she gives personal care to residents without supervision unless the resident requires more than one carer. In allowing staff to work unsupervised, without a Criminal Records Bureau check means the home is not complying with the regulations and this practice may put residents at risk. This was discussed with the manager who said she thought it was acceptable as the carer had a Criminal Records Bureau check from her last employer but would take action to ensure this person does not provide personal care unsupervised. It was identified that a large part of the induction training for one member of staff had been completed in one day. It is anticipated that induction training is carried out over a six-week period to ensure that staff have an in-depth knowledge of the home’s routines and enable them to meet residents’ needs. Foundation training programmes are in place ensuring that staff are competent to meet residents needs. Information in the pre-inspection documentation showed that of the sixteen care staff ten have achieved National Vocational Qualifications in care at level 2 or above. Currently homes are required to have a plan do demonstrate how the home will achieve 50 of care staff with this qualification by April 2007 therefore the Standard is exceeded. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from clear leadership and direction and most aspects of residents’ health, safety and welfare are protected and promoted EVIDENCE: The Registered Manager is suitably qualified and experienced to run the home and provides clear leadership to staff ensuring they are aware of their roles and responsibilities. She is open and approachable and throughout the inspection it was evident that staff, residents and relatives were happy to approach her with any concerns. Currently the manager consults with residents on a one-to-one basis but during this inspection and at the last inspection residents spoken with said they would like residents meetings to be arranged. This was discussed with the manager who agreed to explore strategies for ensuring that residents’ are Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 20 consulted as a group. One of the directors of Ingham House Ltd makes monthly visits to the home to inform the quality monitoring process and the subsequent reports are available for inspection. Staff meetings are undertaken regularly and the minutes available for inspection and these are in addition to the hand over sessions at the end of each shift. The manager has created a format for gathering information to inform the quality monitoring process. These need to be further developed into formal quality assurance and quality monitoring systems to enable the provider to critically evaluate the service and ensure it is run in residents best interests. Residents are responsible for their own finances if appropriate; relatives and solicitors support others. When items are purchased on behalf of residents, receipts are obtained and satisfactory records maintained. Although a staff training programme has been devised it was of concern that a newly recruited carer was bathing a resident alone and when interviewed confirmed she delivers personal care alone but had not received the mandatory training in manual handling. This needs to be addressed to ensure staff and residents are not put at risk. Pre-inspection information provided by the manager indicates that all health and safety checks are made and recorded. In addition this documentation confirmed that staff have been trained in fire safety and regular fire drills are carried out. A tour of the premises found that a number of fire doors did not close properly and this needs to be addressed as it puts both staff and residents at risk in the event of fire. Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X X 2 Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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 13 (4) (b) (c) Requirement Timescale for action 07/09/06 2 3 4 OP19 OP30 OP29 5 OP32 6 OP33 7 OP38 Risk assessments need to be expanded to include the management of the risk and be regularly reviewed. 23(1a) That all parts of the home, are (2b) properly maintained and all repairs undertaken as necessary. 18(1ac) That induction is carried out in (i)(ii) accordance with the Care Sector Skills Council guidance. 19(4)(a-c) That all staff provide the required documentation prior to appointment, including Criminal Records Bureau checks and a health declaration. 12(1)(2) Evidence needs to be provided to (3)21(1) demonstrate residents are regularly consulted, their views sought and acted upon as under Reg. 24(1). (timescale of 18.07.05 and 01/01/06 not met). 24(1)(ab) That formal quality monitoring (2)(3) and quality assurance systems be created and implemented (timescale of 01/01/06 not met). 13 (5) All staff need to be trained in manual handling. (timescale of 14.06.05 and 01/12/05 not DS0000067336.V307832.R01.S.doc 07/09/06 07/09/06 07/09/06 07/09/06 07/10/06 07/09/06 Ingham House Ltd Version 5.2 Page 23 8 OP38 23(4a) (c)(i) met). That all fire doors fire doors close properly. 07/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Ingham House Ltd DS0000067336.V307832.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!