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Inspection on 12/07/07 for Ingleside

Also see our care home review for Ingleside for more information

This inspection was carried out on 12th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. People who use the service appear to have a relaxed lifestyle supported by staff that are knowledgeable with regards to their individual needs. The home provides a number of activities for those that choose to participate. People who use the service are encouraged to exercise choice over their daily routines, and are able to participate in a range of activities. The food on offer is home cooked and of a good nutritious standard, people who use the service commented positively on both the quality and quantity of the food on offer. The home undertakes a range of quality audits to ensure that the standard of service provided is maintained and improved upon. Service users and relatives spoken with were pleased with the care provided. The home has a very low turnover of staff thus offering good continuity to the people who use the service.

What has improved since the last inspection?

The service continues to update the environment and there is good evidence of inward investment in the home. The registered manager has now enrolled on a suitable qualification in care management to complement their extensive experience in the care home sector. Staff and people who use the service have been consulted on their views of the home and how it could be improved. Staff training continues to be taken up and arrangements are now in place to ensure that staff have supervision on a formal basis.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Ingleside 648 Dorchester Road Upwey Weymouth Dorset DT3 5LG Lead Inspector John Hurley Key Unannounced Inspection 12th July 2007 8.40am 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 Ingleside DS0000026824.V343457.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. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ingleside Address 648 Dorchester Road Upwey Weymouth Dorset DT3 5LG 01305 812667 01305 813383 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) Mr Christopher James Webb Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two rooms may be used as doubles. Date of last inspection 8th May 2006 Brief Description of the Service: Ingleside Residential Care Home is established in a large semi-detached house set back from the main Dorchester to Weymouth road in the village of Upwey. The home is registered to accommodate 17 elderly people and has been owned and managed by Christopher Webb for the past 22 years. In total there are fifteen bedrooms available in a combination of 13 single and 2 double rooms. Bedrooms are situated on the ground and first floor of the house. The first floor is accessed by chairlift on the main staircase or by a back staircase. The communal facilities include two lounges, a separate dining room and a conservatory that overlooks the front garden. The fees range between £353 and £493 per week. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of Ingleside care home for the inspection year 2007/8. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. The unannounced inspection lasted eight hours. The views of the people who use the service and people important to them were also sought; where appropriate their comments are included in this report. The inspector toured the building, spoke with the management and staff on duty and spoke privately with people who use the service on both an individual and group basis. They also spoke with a number of visiting relatives and joined the resident group for lunch. They inspected a sample of the documentation relating to the individuals who reside at the home along with records relating to staff and other documents required by regulation. What the service does well: People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. People who use the service appear to have a relaxed lifestyle supported by staff that are knowledgeable with regards to their individual needs. The home provides a number of activities for those that choose to participate. People who use the service are encouraged to exercise choice over their daily routines, and are able to participate in a range of activities. The food on offer is home cooked and of a good nutritious standard, people who use the service commented positively on both the quality and quantity of the food on offer. The home undertakes a range of quality audits to ensure that the standard of service provided is maintained and improved upon. Service users and relatives spoken with were pleased with the care provided. The home has a very low turnover of staff thus offering good continuity to the people who use the service. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The registered manager needs to improve and ensure that ; • the care planning and care review process is better managed in order to be able to ensure that the people who use the service needs are being met in a consistent and proactive way. staff are suitably trained in how to carry out risk assessments and ensure that action is taken to minimise any risks identified through the risk assessment process in order to protect the people in their care there is a recorded rationale for the administration of medication via the per required needs route. These measures will ensure that the practice of giving medication to the people who use the service is safe. the services vulnerable adult policy reflects the local authorities protocols in relation to this issue. This will ensure a consistent approach when dealing with these issues. Infection control policies are not undermined by poor practice. • • • • Further more it would be helpful if the registered manager considers their approach to the handling of medication, which should be treated as a controlled drug. It would also be helpful if staff meetings were established to ensure consistency of approach to care practices and the sharing of ideals for improvement. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 7 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. Ingleside DS0000026824.V343457.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 Ingleside DS0000026824.V343457.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): 1,3,6 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home ensures that prospective residents are provided with appropriate information regarding the home. People who use the service and their families are invited to visit the home and assess the services provided. All prospective residents be it permanent or respite must have their needs robustly assessed in order to ensure the well being of the individual looking to stay at the home. Intermediate care is not a feature of the service offered at Ingleside. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities provided at Ingleside. These documents have been updated since the last inspection. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 10 The Registered Manager generally ensures that arrangements are made to carry out an assessment of need, which in the main is completed prior to any service user moving into the home. However, gaps in this process were found, especially in relation to one recent respite admission that had turned into a permanent placement. Although the pre admission assessment had been made and a decision had been made that the home could meet the needs issues identified as potential risks had not been followed up prior to commencing the placement such as the risk of falling. Through discussion with the people who use the service and visiting relatives the inspector established that prospective residents and their families are invited to visit the home prior to admission to establish if the home would suit their needs. Two recent admissions reported that the process was supportive and informative. Through discussion with the homes manager and staff the inspector established that intermediate care is not a feature of this service. Ingleside DS0000026824.V343457.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): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care records do not provide sufficient detail to ensure that individuals personal needs are being fully and safely met. Significant incidents do not influence care plans. The home has systems in place for managing residents’ medicines but some aspects need improving to protect residents. Staff treat residents with respect and dignity, promoting residents’ feelings of worth as valued members of the household. EVIDENCE: The inspector sampled the residents’ documentation in relation to care planning and review and found that in most cases each individual had a usable care plan which demonstrates the people’s needs and how these should be met. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 12 In one case a person had recently come in on respite care, which had now, became a permanent placement. This person had a good preadmission assessment but this had not been translated into a working care plan. In a number of the care plans it was noted that they had been reviewed and signed as no change. However when the inspector looked through the accident book they noted that a person who uses the service had a bad fall in the stairs area, which had required them to be in hospital for a short period of time convalescing at the home. The stated action to stop any further reoccurrence was positive in as much as the person was offered and moved to a ground floor room thus eliminating the risk of further injury on the stairs. But the care plan and review had not be updated at the time or subsequently afterwards to evidence the changing care needs following the fall thus undermining the integrity of the care plan and reviewing procedures. Weight monitoring had been started but was not fully completed on a monthly basis, it would be helpful if this were, in order to track any changes in the individual’s circumstances and take a proactive approach with regards to nutritional screening. It would also be helpful if tissue viability assessments were undertaken to ensure that any person who uses the service is not at risk of developing pressure ulcers due to the lack of acknowledgement of the possible risk. The inspector noted that at least one individual has dementia. On sampling this persons file the care plan demonstrated a number of needs that this person has and how they will met them . Although this plan was basic it was found to be well written and easily understood. To further improve the plan a number of issues need to be acknowledged so that strategies for addressing this persons complex needs can be developed, for example a detailed social history may inform staff of some of the meanings of the actions the person is trying to communicate to them thus making it a less frustrating relationship for all involved. The inspector viewed the medication administration recording sheets and noted a number of issues that needed to be addressed. Some directions required medication on a Per Required Needs (PRN) basis but the rationale for administration on this basis was not available (either on the medication sheets or service users file). The inspector noted that a medication, which is recommended to be treated as a controlled drug was contained within a dossette box as made up by the pharmacist. As the whole of the dossette box was locked away in secure storage it is considered that this is acceptable. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 13 Staff were observed knocking on doors before entering. People who use the service are able to meet privately with visitors in their bedroom or one of the lounges. Interaction between staff and residents was friendly and respectful. The inspector was able to talk with many of the people who use the service some of which by choice spent some of their time in the privacy of the own rooms. These people expressed how much they appreciated that the care staff respected their privacy and dignity and that they were not made to do anything they did not wish to, such as attending activities or having meals in the dining room. They further confirmed that all personal care was provided in the privacy of their bedrooms or bathrooms. Ingleside DS0000026824.V343457.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pace of life at the home appears to meet the expectations of the resident group allowing a relaxed way of living. Service users are encouraged to exercise choice over their lives, giving them opportunity to make their own decisions. Meals are of a good standard and offer a well-balanced diet which enahces the health of residents. EVIDENCE: The inspector observed staff being kind and caring towards people who use the service. Staff spoken with demonstrated a good awareness of how to meet individual’s needs. Their comments included ‘staff couldn’t be kinder or more friendly’ and ‘the staff are very good’. The feedback from people important to the service users further confirmed these observations. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 15 People confirmed that they could spend their time as they want to and that they are given choices. Their rooms are personalised with their own possessions. They can access their personal records on request in accordance with the Data Protection Act 1998. The inspector spoke with some visiting relatives who informed them that they could visit when they wished, within reason, and were always made welcome in the home. They further commented that they are kept informed of how their relative has been and of any emerging issues that they should be aware of. One visitor informed the inspector that since their relative had come to live at Ingleside they (relative) had returned very much to their old cheerful state, apparently a far cry from when they came in some months ago. The feedback received via questionnaires evidenced good levels of satisfaction with the services on offer. Although one questionnaire out of the six returned raised an issue about activities in the main all were positive. The inspector joined a small group of individuals for lunch and discussed the pace of life at the home. They were informed that although there was not a lot of a planned activity this suited them. A person informed the inspector that they were confident if they asked a member of staff if they could go out for a walk or to help them exercise then arrangements would be made. The food that was served was of good quality and more was offered to those who wished extra. The people who use the service confirmed that this was always the case. They further confirmed that the food is good, home cooked and plentiful. They further informed the inspector that they are offered a choice and that staff knew what they liked and would make alternatives if the planned menu did not suit them. The dining room was pleasant with the tables attractively laid. Ingleside DS0000026824.V343457.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service users and people important to them consider that their views are listened too and comments made are acted upon. The management need to update their policy regarding vulnerable adult procedures in relation to multi agency working in order to protect the people who use the service . EVIDENCE: The inspector was informed that no complaints have been made since the last inspection. The people who use the service and people important to them confirmed to the inspector that they felt confident that they could raise issues with the staff or management and these would be dealt with sensitively and promptly. The home has a comprehensive complaints policy that has recently been updated to now meet the National Minimum Standards. The registered manager informed the inspector that most of the staff had attended protection of vulnerable adults training. The staff the inspector spoke with impressed as people who would report concerns of a vulnerable adult nature. Ingleside DS0000026824.V343457.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): 19,21,23,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from continued inward investment. The home has been decorated and furnished to a good standard. There are sufficient communal areas and bathroom facilities to meet the needs of those who live there. More needs to be done in relation to ensuring infection control measures are robust to ensure the wellbeing of those who live at the home. EVIDENCE: The inspector toured the premises accompanied when they first entered the home inspecting a number of communal areas. They found that the home was Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 18 generally clean in all areas observed. It was noted that all toilet and bathrooms were found to be clean and hygienic. The individuals accommodation is provided over two floors. There is a stair lift which has recently been updated, assisted bathroom and call system available to people who use the service. Individuals who the inspector spoke with commented that call bells are answered promptly. There a two large communal lounges and one dining room. One of the lounges was being completely redecorated at the time of the inspection. The communal areas are domestic in nature providing comfortable seating. The corridors are well illuminated with a number of prints on the walls. People informed the inspector that they are able to bring personal possessions with them into the home. The inspector looked at a sample of the bedrooms used by people who use the service and found that they had been personalised with pictures, furniture and photographs to reflect the individuals taste. The inspector noted that the laundry is on the second floor of the building. Through discussion with the staff it was established that dirty clothing is collected for laundering in one of two large yellow buckets, clean laundry being returned to the individuals again in one of the yellow buckets. It would be helpful if containers for clean and soiled laundry were at least of a different colour so as to maintain robust infection control practices. The inspector was informed that all bed linen and towels are sent to an outside contractor for cleaning. Ingleside DS0000026824.V343457.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): 27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff team are knowledgeable with regards to the people who use the service needs and aspirations. There are sufficient staff on the rota to meet the needs of the people who live there. It would be helpful if more training was available that focused on the specific needs of the current resident group. EVIDENCE: The registered manager confirmed there is enough staff on each shift to meet the service users needs. This was also confirmed by service users who commented that staff are always available to help and were very attentive. There are a minimum of two care staff on duty at all times. There have been no new staff recruited since the last inspection. As recruitment was not highlighted as a problem or any requirements set in relation to this standard the inspector did not look at the historical recruitment practices. However through discussion with the registered manager it was clear that they are aware of the expectations of the Care Standards Act 2000 in relation to this issue. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 20 The inspector viewed a sample of the staff files which evidenced that staff are receiving regular supervision. Staff stated that they enjoyed working at the home, and received appropriate support. The files further indicated that staff have undertaken mandatory training in areas such as Moving and Handling, Food Hygiene, Infection Control and general vulnerable adults issues. Some staff have also attended various day courses and are undertaking the NVQ Award in Care at varying levels. Through discussion with the staff group and by observing the people who use the service it is reasonably clear that the staff team have a natural empathy for the people who live at the home. There were many good examples observed of staff interacting positively with the people who use the service for example sitting down and talking with an individual who had become distressed for the third time in the past hour. The distress appeared to relate to the individuals diagnosed dementia. The staff reaffirmed the individual’s perceived reality and gently guided them, through discussion, to a state of mind less distressing. This natural empathy cannot easily be taught but can be built upon by careful management and further training in this area. Therefore the inspector would strongly recommend that plans be made to ensure all staff have training in dementia care. Ingleside DS0000026824.V343457.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): 31,32,33, 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There needs to be a development in the care management and review process to ensure that people’s needs are met at all times. Staff are adequately supervised. There are appropriate systems in place to obtain the views of the people who use the service. The practices at the home do not consistently promote and protect the safety and welfare of the residents. Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has been at Ingleside for the last 21 years. They have a wealth of practical experience and have ensured that they have kept abreast of social care issues through training seminars and provider conferences. Prior to the inspection the registered manager submitted an Annual Quality Assurance Assessment. This document was well presented and detailed the areas of improvement that have been made and further identified the areas that the home wishes to improve on. At the last inspection a requirement was made that they should make arrangements to enrol and pursue a recognised qualification in care to further enhance their practical experience. The inspector is pleased to report that this requirement has been attended too and evidence was available to state that they have now enrolled on an NVQ level 4 in care management. Similarly there has been good progress made with regard to introducing a quality assurance system to the home. The inspector was shown a folder that contained all of the completed questionnaires from people who use the service and staff. It was noted that the staff questionnaires raised a number of issues especially in relation to training. Through sampling the staff training records it is reasonable clear that some parts of the information received in relation to the quality assurance review has impacted on the way the training has been prioritised. Another requirement relating to staff supervision, which had been left unattended to for some time has now been fully met. The inspector viewed the documentation available and found that supervision is now being carried out on a regular basis. The inspector spoke with the manager and designated person responsible for carrying out care needs assessments at some length over the course of the inspection. In the main the records relating to care plans are well written and identify a number of key areas. However some issues relating to risk assessments identified the need for staff to be further trained in relation to carrying out full and comprehensive assessments in relation to a number of risks as already discussed under section two Health and Personal care. It would also be helpful to have key staff trained in the psychiatry of old age (ie dementia) so that the assessment process prior to taking up residency is more robust. The inspector looked at the incident accident book and noted that in the past accidents had been evaluated but these evaluations had not recently been Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 23 made and so any patterns or trends are not identified. This needs to be reintroduced and used when carrying out the monthly review of the persons needs. The inspector considers the approach of only having one member of staff responsible for care planning, assessment and review of needs is a weakness in this service especially in relation to the reviewing process. The registered manager acknowledged these comments at the time of the inspection and agreed to look at the management of these points in light of these discussions. At the time of the inspection staff meetings were not being formally held although the registered manager told the inspector of plans to start these in the very near future. The health and safety of the service users and staff are dealt with adequately with some attention to risk assessments required to further improve in this area as highlighted in earlier sections Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 24 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 x 3 x 3 x x 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 x x x x 2 Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The responsible individual must make arrangements to ensure that there are robust systems in place to ensure that Recording the rationale for administering Per required needs’ administration of medication. These measures will ensure that the practice of giving medication to the people who use the service is safe. A service user care plan must be drawn up for all service users. This requirement is repeated – the previous date to have complied with this is the 01/08/06 3 OP30 18(c)(1) The registered person must ensure that the persons working at the home receive training appropriate to the work they are to perform ie risk assessments. The registered person must ensure that when the home identifies health related risks, DS0000026824.V343457.R01.S.doc Timescale for action 14/08/07 2. OP14 Reg 15(1) 14/08/07 31/08/07 3 OP8 14(1)(a) 14/08/07 Ingleside Version 5.2 Page 26 risk of falls, nutrition and the potential for the development of pressure ulcers, a suitably qualified or suitably trained person undertakes assessments. The residents care plan must record how the identified risk is to be managed. 4 OP18 13(6) The registered person must ensure that the homes policy with regards to vulnerable adults reflects the local authorities policy in order to protect the people who use the service. The registered person must ensure that the homes policy in relation to infection control is not undermined by practice in order to protect the people who use the service form unnecessary risks. 01/09/07 5 OP38 16(J) 01/08/07 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 3 Refer to Standard OP7 OP30 OP32 Good Practice Recommendations Care reviews should be more meaningful instead of the stock use of phrases such as no change. The registered manager should consider sourcing training for staff in mental health issues associated with old age The registered manager should consider holding full staff meetings Ingleside DS0000026824.V343457.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. 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