Inspection on 24/01/07 for Ingham Old Hall Residential Care Home

This inspection was carried out on 24th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ingham Old Hall Residential Care... 13/10/05

Ingham Old Hall Residential Care... 12/05/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ingham Old Hall Residential Care Home Sea Palling Road Ingham Norwich Norfolk NR12 0TW Lead Inspector Silas Siliprandi Unannounced Inspection 24th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ingham Old Hall Residential Care Home DS0000063055.V330022.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 Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ingham Old Hall Residential Care Home Address Sea Palling Road Ingham Norwich Norfolk NR12 0TW 01692 580257 01692 580297 inghamoldhall@aol.com 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 Healthcare Ltd Miss Karon Leonard Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Ingham Old Hall is a residential care home providing personal care and accommodation for up to twenty-five older people. It is a detached, two storey, period house that has retained many of its original features and in parts dates back to the fourteenth century. There is a passenger lift to the first floor and residents have communal use of a lounge, entrance hall sitting area, conservatory and dining room. The home has twenty-four bedrooms, one of which is a double bedroom and all have ensuite or designated washing and toilet facilities. There is a communal toilet and bathroom on each floor with a shower facility on the first floor and an additional toilet on the ground floor. The home is sited in it’s own, large, well kept grounds with parking adjacent to the building. The home lies within the boundary of the village of Ingham which itself lies approximately 1.5 miles from the small town of Stalham which offers shopping and health care amenities. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was part of the normal programme of visits, it was unannounced and was spread through the morning, afternoon and early evening of Wednesday 24 January 2007. Two service users, two visitors and three staff were interviewed and the owner and his manager were also available to talk about the home and its progress. The inspection also took in looking at the public areas of the building, and with permission, individual service user bedrooms. Prior to the site visit, information had been made available by the service provider. The service users and their representatives had sent comment cards telling the commission their individual views on the home as they saw it. Five service users sent their comments to the Commission and eighteen service users relatives or representatives also wrote to us. The inspection generally confirmed what the prior information [and individual commentators] had to say. All the individual respondents were wholly satisfied that their medical and physical needs were always properly taken care of. All the respondents said that the home was always clean and tidy. All were satisfied that staff paid proper attention to them and treated them with due respect. There was some division of opinion about the choice of meals, but the overwhelming consensus was that the meals themselves were good. A similar mixed picture emerged when people came to evaluate the type and choice of activity in the home, but again the overall picture was favourable rather than unfavourable. Respondents were fairly [but not universally] sure about how to bring concerns to light, but to balance this uncertainty people did feel that areas of concern were listened and responded to properly when they did raise them. People all said that staff, ‘Always do their best’, but went on to give instances of where they felt that staff were under pressure or had too much to do, leading to occasional difficulties in getting the appropriate level of assistance. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the home [and especially the new manager] has worked hard to consolidate a wide range of procedures and processes and to rectify areas where work was needed. Specifically, these items have received particular attention:• Service user records have been overhauled and now include more consistent information and a photograph. • The home now has a much better idea of what people want to be done when they die. This isn’t an easy topic to broach, but it is important to know and respect peoples’ individual expectations. • A review has been carried out to gain a better picture of what people want when it comes to daily activities; one member of staff has been given responsibility [good practice] for co-ordinating efforts. • A ‘key worker’ scheme has been started. A key worker is a member of staff who takes particular responsibility for the care of one or more service users. This method of working is known to improve relationships and help individuals living in the home take more control of their lives. This is therefore a really good and solid improvement. Key worker staff interviewed could already identify areas in the lives of those that they worked with that could be given closer attention and improved. This is a very positive sign. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 7 • • • Two Quality audits have been carried out to help the home understand where people who use the service feel that their expectations are being met and where there might be areas for further improvement. This is a good effort given the time that the new manager has been in post. Staff files have also been brought up to date and made compliant with what the law expects. Staff supervision and appraisal has also been introduced, this is another solid professional advance. Good progress has been made on improving [and back-filling] levels of staff training. The home has drawn up a plan for maintenance and re-decoration. A solid start has been made on returning the home to a good level of maintenance and decoration. What they could do better: Since the last inspection in October 2005, the home has introduced some improvements. However, there remain a number of areas where further improvement is required. • The home is not registered to care for people with dementia. Despite this, a number of the current service users have declining mental health. The home needs to decide how to respond either request Norfolk Adult Social Services to reassess those service users with a view to finding more suitable placements or the home needs to apply to CSCI for a variation in their registration. If the home wishes to continue to accommodate people with declining mental health or dementia, it needs to review its care planning, staffing and environment to ensure that these needs can be met. The range of activities on offer need to better reflect the needs and wishes of individual service users. The staffing level needs to be reviewed with a view to an increase. • • • 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. The summary of this inspection report can be made available in other formats on request. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The way in which information is given is adequate. The pre-admission assessment and care response process is now on sounder footing, it now needs to be made more individual. The home needs to review the whole assessment and admission process, especially taking account of the needs of people with failing mental health. The home needs to consider the advisability [or otherwise] of altering the present registration and the present range of facilities and services to provide some part [or all] of its care to those older people with degenerating mental health. The home needs to protect its current registration criteria with an appropriate admissions policy Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a solid foundation for giving information; there are both statements of purpose and service user guides, which have recently been updated. There is also a web site that provides an alternative source of information. The information covers the main points expected in regulation, but has not yet encompassed innovative or personalised ways of helping service users understand the service. This is a probable underlying cause of service user comments about how accessible they felt information was about the home. Comments made by service users about not having detailed breakdowns of the services they would receive ought to have been resolved by the home’s recent attention to any previous shortfalls in this area. There is a process of assessment that the home can use to see if they can meet the prospective service user’s needs, and to begin a dialogue about what kind of care will be given. The assessments made by placing agencies were said to provide a picture that was often inconsistent with the understanding that emerged after admission. The assessment and plans for care were sound in respect of physical and medical needs, but were not yet developed into a robustly ‘person centred’ model. The records of the home showed people with noticeable mental heath needs, this was further evidenced by observation and by what the manager, owner and staff had to say. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessments form a solid starting point; they are now a more consistent record of physical and medical needs. They need expanding to have a wider bearing on the quality of life of individual service users and the control they exercise. The processes of assessment needs to take better account of people with mental health needs. The home either has to stay within its registration criteria or formally broaden its services and registration. The plans for care ought to set out in detail the actions which need to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Peoples’ medical needs were properly taken care of and there are no problems in accessing proper medical advice and attention. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 12 The systems for the administration of medicines were sound. The process by which people choose to have their medicines administered for them [or continue to administer their own medicines safely] ought to be more robust. EVIDENCE: The assessments were now on a sounder footing. The assessments were largely confined to physical and medical needs, there was [as yet] little scope within the process and structure to focus on individual ‘social and emotional issues’. The assessments do now have a standardised format that means consistency in enquiry and recording, even if the base is narrow. The care planning process was at an early stage of development and was not yet focussed on detailed personal expectations or aspirations. There is however some basic material for staff to use uniformly as guidance. Staff were able to describe [in some cases in really graphic detail] areas which would be individually beneficial to service users that they key-worked for. They agreed that none of these useful details were in the plans for care. The manager also agreed that this was so. The manager went on to say that staff had had a need to get to grips with the ‘basics’ of a system before that system could be taken on to set out more detailed and negotiated plans for care that handed more control back to the service users. Neither the assessment process, nor the process for devising appropriate and negotiated care responses were attuned to people with mental health needs. The medicine administration was straightforward and protected by appropriate policies and records systems, this standard [Std 9] was judged ‘good’ at the last inspection and there were no indicators that a full and detailed reexamination were required during this visit. However, the process by which people were electing to hand over the administration of medicines was not clear neither was the process by which self-administration could be assessed and promoted wherever it was safe to do so. The homes own procedures [Statement Of Purpose and Service Users’ Guide] plus specific policies form a foundation that aims to protect individual privacy and dignity. Staff mentioned these concepts specifically when interviewed. Service users were positive in their interview comments as well as what they had to say in their comment cards. Service users’ representatives were equally positive. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 13 The assessment and care planning process has not yet expanded into this area in such a way as to ensure that all appropriate details were sought, recoded and acted on. This is especially true for people with specific mental health needs because the present structures are not designed to address their expectations and needs. The home was still not finding it easy to ask about peoples’ wishes about their very personal preferences how they wanted to be treated as they approached death, and their wishes for their funeral arrangements after death. There was some discussion about the range of ways in which this issue had to be handled to ensure appropriate respect and understanding. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards 12 to 15 were all inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The present care plans therefore need strengthening to underpin the home’s intentions and policies of helping service users exercise choice and control over their lives. The improvements made in respect of having an individual member of staff coordinating activities are already especially helpful. The level of staffing [and this, in part, might be interpreted to mean specialist staff brought in from outside to facilitate some services or events] needs to be strengthened. The new information to be included in enhanced care plans would provide individualised diet and preferred activity information. Visitor contact is satisfactory, improvements have been made in providing a better foundation for community involvement but care plans need re-enforcing at an individual level in this respect. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 15 EVIDENCE: The key evidence here was the way in which the assessment process sought information in respect of these standards and the way in which the process of planning for care in partnership ensures that peoples’ personal preferences are promoted and safeguarded. The present systems only just dip into these waters. There certainly has been progress. A review has been carried out of daily activities, this did not reveal any obvious gaps, but did throw up an understanding of needing to build on the present foundation. A member of staff has been given special responsibility in this area [good practice], And there is an increased awareness generally of the need to keep this area under active review. Staff continued to say that there was not always sufficient time to provide individual activities, they also said that the care planning system was not yet robust enough to include information they had about individual needs and preferences. The daily meal now has a menu choice offered one day in advance. This is an improvement on the previous system. The Senior Housekeeper has just completed level III NVQ which ought to assist in devising and implementing broader strategies for effective consultation and innovation in the range of food choices. The home has good policies in respect of visitors; pre-inspection responses from service users and their representatives express satisfaction, as did interviews on the day. The systems in place to support wider community involvement have improved, but are not yet operational or underpinned by the right kind of assessment and care planning process. The systems are not yet of a kind suitable for people with declining mental health. The present care plans do not yet fully underpin the home’s intentions and policies of helping service users exercise choice and control over their lives. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards 16 and 18 were inspected. Standard 17 was not re inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates sound policies and staff are aware of their responsibilities. EVIDENCE: The home continues to have clear policies, properly available to service users and their representatives. They are not as yet in any form additional to written English text. Policies are in place for the protection of service users and staff were able to describe their implementation. Service users and their representatives were able to describe how they had raised minor concerns and had them dealt with properly. None of the policies and procedures are of the right kind for people with declining mental health. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The maintenance/decoration of the home has improved, but is still not good enough. The new schedule of maintenance/decoration of the home must be pursued vigorously and carried ahead of schedule if at all possible. The facilities provided have a good range, but the layout and facilities of the home need urgent review to ensure that they do meet the stated purpose of the home and all the service users accommodated. A risk assessment ought to be carried out to ensure that the present hot water supplies to all parts of the home used by service users constitutes safe practice. The general level of cleanliness continues to be good. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 18 EVIDENCE: Since the last inspection a schedule of remedial works has been drawn up and a sound start made on improving the levels of maintenance and decoration. There is still a very long way to go and considerable portions of the home are at [or beyond] the end of their service life in terms of decoration and maintenance. The present assessment process is not wholly adequate to determine the way in which the building needs to be adapted to make it suitable for its stated purpose. The needs of service users currently accommodated are probably not well met by the building and its services and facilities. For example, there are numerous level changes and the access to the first floor is by one small lift that is not easy for everybody to use. Other features of the home continue to provide a satisfactory level of service and service users again say that the home is kept clean and tidy. There was discussion about the potential the building has for adaptation to meet the needs of people with declining mental health. The present building does not easily lend itself to this use at present. For example the home has no means of controlling water temperatures in all areas used by service users. This may also pose a risk [or limit choices] for some of the existing service users. The home was clean and tidy in all areas toured. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were properly screened and recruited, and the home has worked extremely hard to fill in previous training gaps. Staff do know people as individuals, and service users are complementary about their care. There is a shortage of staff that must be made good. Staff training needs to be continued at its present pace and will need extending into more focussed work with person-centred care planning. It would seem important to look at the need for some specialised training for meeting the needs of older people with specific health needs. EVIDENCE: When looking at pre-inspection information, including service user comments it appeared as if there was a shortage of staff. Not a really bad shortage, but a chronic one. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 20 During the inspection evidence of service user need, the staff records, the staffing rosters, staff interviews, service user interviews and discussions with the manager on the day all underpinned this impression. It was agreed that there was [at least] a shortage equivalent to one and a half full-time staff posts. It was agreed that this affected service users. Existing staff filling in missing hours dampened some of the potential ill effects on service users. Active recruitment ought to make good this deficit in the immediate future. The staffing turn over had been high, but there were acceptable reasons, and matters were now far more stable. Staff were able to demonstrate personal knowledge of individual service users, giving better verbal accounts than could be found in written records. Service users said that staff treated them with proper respect, and that they were considerate and kindly. A lot of commendable work has been put in with basic training and backfilling of training and an active programme is in place. The staffing recruitment procedure continued sound. There was no particular training input for staff in respect of people with declining mental health. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager has worked very hard to consolidate systems and structures in the home, including making a very sound start on staff supervision and training. There is some way to go, but this cannot detract from good progress already made. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the last inspection a new manager has been appointed to the home and registered with the Commission. The new manager has the skills, experience and competencies to manage the home. A lot of their hard work has gone into consolidating previous work and enlarging on it. The result of this is a much sounder organisation and a steadily improving level of satisfaction. There is a limit to what can be done in any given time, but it is abundantly clear that the home now can move ahead to meeting its own ambitions thanks to this work. There have been two ‘Quality Audits’ since the last inspection. These show general satisfaction and have been used as evidence in this report. There was some discussion about the real benefit of attuning the question sets in the Audit to the home’s own Statement of Purpose in future. There was no money handled directly for service users. However, there was money being held from service users’ representatives. Some instances were found of an incomplete audit trail, and a suggestion was made about getting representatives’ signatures approving each block of transactions. Supervision/appraisal is now in place for staff. The records were clear, and the ground covered was already developing well. The discussions were laid out in a very accessible way. A comprehensive record of safety checks etc was presented by the provider prior top the inspection. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 23 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 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X X STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 4 X 3 Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Continuation of maintenance/deco ration 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 OP3 Regulation 14 Requirement The persons registered must review and broaden the current assessment of all service users in the home. The persons registered must draw up detailed plans for care in conjunction with each service users to ensure that the service user’s personal and social care needs are set out in detail. The persons registered must ensure that the premises of the home and the physical services of the premises meet the expectations of the registration category of the home and the statement of purpose of the home. The persons registered must continue to pursue the new programme of maintenance and re-decoration with vigour. The persons registered must ensure that at all times sufficiently qualified, competent and experienced persons are working in the care home in such numbers as are appropriate for DS0000063055.V330022.R01.S.doc Timescale for action 01/07/07 2 OP7 15 01/07/07 3 OP19 16 01/07/07 4 OP19 23 01/02/08 5 OP27 18 23/02/07 Ingham Old Hall Residential Care Home Version 5.2 Page 25 the health and welfare of service users. There is an immediate need to strengthen the present complement. 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 OP33 Good Practice Recommendations It is recommended that the present system of assessing service user satisfaction about services is reviewed by seeing how closely evaluation could be aligned with and linked to the statements made in the home’s own Statement of Purpose. Ingham Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Old Hall Residential Care Home DS0000063055.V330022.R01.S.doc Version 5.2 Page 27 - 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. 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