Inspection on 22/05/07 for Inglemere House Residential Home

This inspection was carried out on 22nd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Inglemere House Residential Home 13/05/10

Inglemere House Residential Home 05/11/09

Inglemere House Residential Home 15/05/08

Inglemere House Residential Home 28/09/06

Inglemere House Residential Home 01/09/05

Inglemere House Residential Home 05/05/05

Inglemere House Residential Home 16/12/04

Inglemere House Residential Home 07/09/04

Inglemere House Residential Home 05/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Inglemere House Residential Home Waterloo Road Crowthorne Berkshire RG45 7NW Lead Inspector Joan Browne Unannounced Inspection 22 May 2007 11:45 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 DS0000011127.V335822.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. DS0000011127.V335822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglemere House Residential Home Address Waterloo Road Crowthorne Berkshire RG45 7NW 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) 01344 772120 F/P 01344 772120 Mrs Yuen Yuen Jackson Mrs Yuen Yuen Jackson Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places DS0000011127.V335822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2006 Brief Description of the Service: Inglemere House is situated in Crowthorne a short distance from the high street and other local amenities. The home is owned and managed by Mrs Yuen Jackson and has been in operation since 2000. It provides personal care for up to fourteen service users. Service users are accommodated in single rooms, which are found over three floors. All rooms have vanity basins and one room has an en- suite. The home has four dayrooms and one dining room. These communal areas provide space for receiving visitors, participation in activities and watching television. A ramp is situated at the front door of the building to accommodate wheelchair users. There is a lift, which permit access to all levels of the home. Grab rails are found in toilets, bathrooms and bedrooms. The home possesses hoisting equipment to facilitate safe moving and handling practice and a call bell system is in place. The staff team consists of the owner/ manager who is a trained nurse, carers and a maintenance person. The fees for this service range from £400.00-£419.00 per week. DS0000011127.V335822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ and was carried out on 22 May 2007. The inspector arrived at the service at 11.45 am and was in the service for 6½ hours. It looked at how well the service was doing and took into account detailed information provided by the manager, and other information that the Commission had received about the service since the last inspection. The inspector asked the views of people who use the service or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. It was felt that the home was providing an adequate service to ensure that individuals’ cultural and diverse needs were being met. The inspector examined care plans and followed this by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with other records required by regulation. Staff rosters were examined along with staff recruitment files, and training documentation. A tour of the premises was conducted. The inspector spent some time meeting with residents, staff and a visitor that was visiting at the time of the inspection. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: What has improved since the last inspection? DS0000011127.V335822.R01.S.doc Version 5.2 Page 6 Four bedrooms have been repainted to ensure that people using the service live in well-maintained comfortable bedrooms. Floor coverings in one bathroom and toilet area have been replaced to ensure that the communal area is safe and habitable for people using the service. 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. The summary of this inspection report can be made available in other formats on request. DS0000011127.V335822.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 DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people’s needs are assessed before they are admitted to the home. EVIDENCE: Case tracking highlighted that the home ensures that a pre-admission assessment is undertaken for prospective service users. The home has developed a brief format for gathering information which forms the basis of the care plan. The pre-admission assessments for the two most recently admitted residents were examined. The two individuals were referred from a placing authority. Evidence was seen to confirm that a summary of the care management assessment and care plan had been obtained. DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service have an up to date care plan. However, individuals’ needs and choices should be clearly reflected in care plans to ensure that care provided is not compromised. The homes medication practice should be reviewed to ensure that it complies with best practice guidelines. EVIDENCE: Three care plans were examined, which were in a booklet form and provided sections for the completion of important information such as personal profile details, activities, mental and physical health assessment, moving and handling assessment, tissue viability, nutritional screening and falls assessment. It was noted that the section relating to individuals wishes in the event of death was not completed. Not all plans were signed by individuals to confirm their involvement. In one particular care plan the section relating to how personal care needs should be provided was very brief and would not allow a new member of staff to care appropriately for the individual. The following information was noted: Little assistant with washing and dressing. DS0000011127.V335822.R01.S.doc Version 5.2 Page 10 A particular resident informed the inspector that it was her wish to be transported in a wheelchair without the footrests being attached. However, this information was not reflected in the individuals care plan. There was evidence that plans were being reviewed monthly. Information in the daily log focussed on personal care provided and eating and drinking. Scribbled out entries were noted in the daily log, which is poor practice. The manager was advised that because the daily log sheets can be used in a court of law or in a complaints investigation the practice should cease. Residents have the option to keep their general practitioner (GP) providing the GP is willing to keep them on or they can register with the GP that visits the home. There was evidence that the district nurse supports the home. The chiropodist visits six-weekly and residents have access to the dentist and optician. National Health Service treatment could be accessed via the general practitioner. There was no evidence that residents weights were regularly monitored but the home carries out nutritional assessments on individuals, which are regularly reviewed. A requirement was made at the previous inspection for all residents to have access to fluids between the last evening meal and breakfast. It is pleasing to report that residents are now provided with jugs of water in their bedrooms. Residents who responded to the Commissions comment cards said that they always receive the care and support and medical attention required. The home uses a monitored dosage system. There were no unexplained gaps noted on the medication administration record (MAR) sheets. However, tippex correction fluid and written over entries was observed on some MAR sheets seen. This is poor practice and should be ceased because the MAR sheets are legal documents and could be used in a court of law or in a complaints investigation. As part of the homes good practice procedure and to comply with the Royal Pharmaceutical Guidelines the home should retain a list of staff members authorised to give medication, which should include a record of their approved initials. The inspector observed staff as they assisted residents in their activities of daily living and on most occasions apart from the incident at lunch time residents were treated with dignity and respect. Individuals preferred term of address was recorded in care plans seen. Residents spoken to during the inspection confirmed that their rights to privacy and dignity were upheld. DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home should ensure that files belonging to people who use the service are stored appropriately to ensure that confidentiality is not breached. The practice in place at mealtime would need to be reviewed to ensure that people who require help with feeding are offered sufficient time to finish their meal comfortably. EVIDENCE: The home provides a range of activities such as board games, sing song, exercise to music and quizes. Outside entertainers visit the home twice monthly to perform. A christian religious service is held at the home on a regular basis. On the day of the inspection one resident attened a local day centre. Residents who responded to the Commissions comment cards said that there were always activities arranged in the home. Relatives are able to visit the home at anytime and there are no restrictions on visiting. At the time of the inspection one visitor visited the home and was spoken to. The individual was confident that residents were receiving a quality service and was complimentary about the manager and her staff team. DS0000011127.V335822.R01.S.doc Version 5.2 Page 12 There were no residents handling their own financial affairs. This was being done by family members. No residents were using the services of an advocate at the time of the inspection. Residents files were observed on a shelf in the kitchen area. It is required that files must be kept in a secure storage area to ensure that confidentiality and data protection are not breached. The midday meal was observed. Some residents chose to remain in the sitting room for their lunch and in their bedrooms. The dining table was set with cutlery, tablecloth and condiments. It was noted that the fruit squash was poured in individuals glasses for a considereable period of time before lunch was actually served, which meant by the time it was ready to be drunk it was warm. The practice looked institutionalised and was discussed with the manager. She has agreed to review it. Lunch consisted of boiled potatoes, casserole pork and peas. Tapioca pudding was served for dessert. It was noted that lunch served was not reflective of the menu seen. This was discussed with the manager who said that residents were consulted and made aware of the change to the menu. Residents were complimentary about the food. Those residents who responded to the Commissions comment cards said that they always like the meals. Staff were observed assisting those residents who required asssistance with eating. It was noted that assistance was not always provided in a sensitive manner. For example, the manager was observed assisting a particular resident with feeding. Before finishing the task she commenced serving the dessert to other residents and then continued feeding. The practice observed did not demonstrate that the individual was being assisted in a sensitve manner neither did it reflect that the individual was given time to finish their meal comfortably. The manager informed the inspector that she provides food for special occasions for individiduals. It was noted that the home had been awarded a bronze award for standard of cleanliness in the kitchen and food preparation. DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a complaints procedure, which should ensure that people who use the service are able to express their concerns and are confident that they will be listened to. The home has a safeguarding of vulnerable adult procedure and staff have been trainined in the safeguarding of vulnerable adults, which should ensure that people who use the service are protected from any potential abuse. EVIDENCE: Information on the pre-inspection questionnaire indicated that the home had received one complaint about the service since the last inspection, which was investigated. It is pleasing to report that no complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Residents who responded to the Commissions comment cards said that they always know who to speak to if they were not happy. They all said that they knew how to make a complaint. The homes complaints procedure was displayed in the home. The Commission has not received any information concerning any suspicion or evidence of abuse or neglect made to the service since the last inspection. Staff spoken to were aware of the homes safeguarding of vulnerable adult policy and procedure and what action should be taken if they suspected or DS0000011127.V335822.R01.S.doc Version 5.2 Page 14 witnessed an incident of abuse. Information submitted on the pre-inspection questionnaire in section D6 indicated that staff had undertaken training in the safeguarding of vulnerable adults. DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Maintenance matters will need to be addressed to enable people who use the service to live in a safe well-maintained environment. EVIDENCE: The inspector toured the home and found all areas of the premises to be in need of decorating. The chairs in the main lounge looked worn and tired. Some chair covers were torn. It was noted that the ground floor lounge door, the door near to the ground floor bathroom and kitchen door were wedged open. A requirement has been made in this report for doors not to be wedged open. It is acknowledged that four bedrooms had been repainted since the last inspection. However, a large number of bedrooms and bathrooms seen were desperately in need of decorating. The shower room on the second floor looked like it was being used as a storage area. Chairs and other articles were stored in the shower cubicle. Arrangements should be made for articles to be DS0000011127.V335822.R01.S.doc Version 5.2 Page 16 removed from the shower cubicle. The garden fence was damaged, which was caused by the recent storm and needed to be repaired. The home does not have a maintenance plan in place. The manager said that the requirements made at the last fire inspection had been complied with. The following maintenance matters were identified as needing attention: • The cracked glass in the ground floor lounge window must be replaced • The floor boards in bedroom 4 pose a hazard and must be replaced • The floor boards in the ground floor bathroom pose a hazard and must be replaced • The damaged garden fence must be repaired The premises were clean hygienic and free from offensive odours. Residents who responded to the Commissions comment cards said that the home was always’ fresh and clean. The laundry facilites were sited away from where food was stored, prepared, cooked and eaten and were generally in a satisfactory order. Washing machines had the specified programming ability to meet disinfection standards. DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service are cared for by staff who are appropriately trained and competent to meet their diverse needs. The homes recruitment practice should be reviewed to ensure that persons who visit the home to provide regular service or support to people who use the service obtain a CRB clearance. EVIDENCE: The staff rota examined indicated that there were two care staff on duty throught the day and one waking night staff with the manager sleeping on the premises. The manager and two staff were on duty throughout the inspection. At the time of the inspection there were no domestic staff employed. The chef position remained vacant and the manager said that she was responsible for cooking all the meals. Residents who responded to the Commissions comment cards said that staff were always available when needed. Those residents spoken to during the inspection were complimentary about the staff. The following comments were noted: Staff are very good. Staff look after me very well. I was very ill when I came here. Now I am the picture of health because staff look after me very well. DS0000011127.V335822.R01.S.doc Version 5.2 Page 18 Information on the pre-inspection questionnaire indicated that five staff had obtained the national vocational qualification (NVQ) in direct care at level 2, which meant that the home had achieved the minimum ratio of 50 staff holding an NVQ qualification. Files for the two most recently appointed staff members were examined. Files were generally in good order with all necessary checks carried out for the protection of residents. However, it was noted that in one file a verbal reference had been obtained and there was no evidence that it was followed up by a written one. The manager was advised that two written references should be obtained before appointing a member of staff. It was noted that criminal record bureau (CRB) clearances had not been obtained for the hairdresser and the maintenance person. The manager was advised that persons who visit the home to provide regular services or support to the residents must undertake PoVA first and CRB clearance to ensure their sutability and to protect and support residents from any potential harm. A requirement has been made in this report for the home to ensure that CRB clearances are obtained for these personnel. Information submitted in the homes pre-inspection questionnaire under section D6 indicated that during the last twelve months staff had undertaken training in emergency first aid, basic food hygiene, PoVA and whistle blowing, health and safety, dementia care, fire awareness training and people handling and risk assessment. The manager confirmed that all new staff receive induction training. Evidence of staff completing the commons induction training was seen. DS0000011127.V335822.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Health and safety procedures are not always robustly followed, which potentially put people who use the service at risk. EVIDENCE: The proprietor/manager is a qualified nurse and holds the registered managers award certificate. She is a hands on person and works alongside the staff team. Residents and staff spoken to during the inspection said that the manager was approachable. Staff confirmed that they receive regular supervision and training to enhance their personal and professional development. DS0000011127.V335822.R01.S.doc Version 5.2 Page 20 There was evidence seen to confirm that staff meetings were held every three to six months. The manager said that the purpose of staff meetings was to ensure that all staff are kept updated on the day-to day operation of the home, to plan and review care practice. Staff are also made aware of the outcome of visits conducted by the Commission and other regulatory bodies such as, environmental health and the fire services. The home does not have an annual development plan. However, the inspector was shown a summary report of the outcome of the homes quality assurance audit. The results indicated satisfaction with all aspects of the service delivery. The manager keeps small amount of cash on behalf of residents in respect of payments for hairdressing and chiropody. The money for two individuals were checked and records tallied with money held. All staff receive mandatory training in fire safety, moving and handling and food hygiene. Regular fire safety checks are carried out and records kept, which were made available to the inspector. There was evidence to indicate that the servicing of the hoists, lift, fire and electrical equipment and boiler was up to date. It was noted that maintenance records needed to be kept in a more secure and better order. This was discussed with the manager during the inspection and she has agreed to review the current system. It was noted that restrictor valves have not been fitted on hot water taps on wash hand basins in residents bedrooms, bathrooms and toilets. Water temperatures were checked in bathrooms and temperatures recorded 54 degrees centigrade. It is recommended that hot water taps on wash hand basins should be risk assessed for the risk they present to the people using the service and action taken to minimise any identified risk. It was also noted that the passenger lift door remained open when not in use. The manager should risk assess the lift for the risk it may present and action taken to minimise any identified risks. A hazardous cleaning product was found in a residents bedroom. The manager was reminded that hazardous chemicals must be kept in a locked storage cupboard. It was noted that the ground floor lounge door, the door near to the ground floor bathroom and kitchen door were wedged open. It is required that doors must not be wedged open. DS0000011127.V335822.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 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 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000011127.V335822.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 15 Requirement The care plan for people using the service must reflect their choice and preference to ensure that they receive person centred support to meet their needs. Timescale for action 30/06/07 2. OP19 23(2)(b) The following maintenance work 31/07/07 must be carried out to ensure that people live in premises that are kept in a good state of repair: • The cracked glass in the ground floor lounge window must be replaced • The floor boards in bedroom 4 pose a hazard and must be replaced • The floor boards in the ground floor bathroom pose a hazard and must be replaced • The damaged garden fence must be repaired Criminal record bureau clearances must be obtained for the hairdresser and maintenance person to ensure that people using the service are protected from any potential risk of harm. DS0000011127.V335822.R01.S.doc 3. OP29 13(4)(c) 30/06/07 Version 5.2 Page 23 4. OP38 13(4)(c) Hazardous chemicals must be kept in locked storage to ensure people using the service safety are protected. Doors must not be kept open with door wedges or stoppers to ensure that people using the service safety are protected from any potential risk of harm in the event of a fire. 30/06/07 5. OP38 13(4)(a) 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations The section in the care plan that refers to people using the service wishes in the event of death should be completed to ensure that their wishes are known and complied with. Scribbled out entries in people who use the service daily log sheets should not be made because sheets are legal documents and can be used in a court of law or complaints investigation. People using the service care plans should contain detailed information to ensure that their care needs would be appropriately met by all staff having to care for them. People using the service should be weighed regularly to ensure that their health care needs are monitored. The home should comply with the Royal Pharmaceutical Society best practice guidelines by ensuring that it retains a list of those staff along with their initials who are responsible for administering medication to people who use the service. The practice of using tippex correction fluid on people using the service MAR sheets is unacceptable and should cease because sheets are legal documents and can be used in a court of law or complaints investigation. Records belonging to people using the service should be kept in a secured storage area when not in use to ensure DS0000011127.V335822.R01.S.doc Version 5.2 Page 24 3 4 5 OP7 OP8 OP9 6 OP9 7 OP14 8 OP15 9 10 OP29 OP38 that confidentiality and data protection are not breached. People who use service should be assisted with eating in a sensitive and discrete manner to ensure that they are given time to finish their meal comfortably and at their own pace. Two written references should be obtained before appointing a staff member to comply with the current guidelines. The hot water taps on wash hand basins in bedrooms and in communal toilets should be risk assessed for the risk they present to the people using the service and action taken to minimise any identified risk. DS0000011127.V335822.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000011127.V335822.R01.S.doc Version 5.2 Page 26 - 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!