Inspection on 31/05/06 for Inglewood Residential Care Home

This inspection was carried out on 31st May 2006.

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

Inglewood Residential Care Home 18/07/07

Inglewood Residential Care Home 30/11/06

Inglewood Residential Care Home 01/02/06

Inglewood Residential Care Home 22/06/05

Inglewood Residential Care Home 10/02/05

Inglewood Residential Care Home 12/07/04

Inglewood Residential Care Home 24/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Inglewood Residential Care Home 139 Dalston Road Carlisle Cumbria CA2 5PG Lead Inspector D Jinks Unannounced Inspection 31st May 2006 10:30 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 Inglewood Residential Care Home DS0000022693.V294361.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. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglewood Residential Care Home Address 139 Dalston Road Carlisle Cumbria CA2 5PG 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) 01228 526776 Mrs Sylvia June Clark Mrs Sylvia Lynn Bendle Care Home 26 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (25) of places Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 25 Older People And 1 Older Person with Dementia Date of last inspection 1st February 2006 Brief Description of the Service: Inglewood is a care home providing residential care for up to 26 older adults, one of whom may have dementia. The home is an older property, which has been adapted for its present use. It is situated approximately one mile from the city centre. The accommodation for service users is provided on two floors, and there is a passenger lift and stair lift. Two people share one bedroom; the remaining rooms are for single occupancy. A large number of the bedrooms have en-suite toilet facilities. There are bathrooms, which are equipped to assist people with a disability. There are two communal lounges and a dining room. People who wish to smoke can do so in the conservatory. The home has a pleasant garden to the front of the home with seating and there is a small car park. The manager has produced an information booklet about the services the home can provide and a copy of the latest inspection report is available at the home. Both these documents are available from the manager on request. The scale of charges are £363.00 per week (June 2006). Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service included an unannounced visit to the home and meeting with the manager and staff working at the home. The views of some of the people living in the home were obtained through discussions and the completion of questionnaires. Comments from relatives and district nurses were also received via questionnaires. The manager of the home completed a detailed questionnaire about the home and the services that it can provide. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to make sure that a detailed assessment of prospective residents needs is obtained prior to the decision being taken to admit the person to the home. This will help ensure that people are not placed in the wrong accommodation. Urgent attention must be given to the way in which new staff are recruited at the home. Some staff have been employed without the proper checks being made. This means that unsuitable staff may be employed, which potentially puts people living at the home at risk of harm. Although people living at the home did not complain about the food, the manager must review the way in which menus are drawn up and produced to ensure that a nutritionally balanced diet is offered at all times. Some of the Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 6 communal areas, for example bathrooms and the conservatory, are in need of some refurbishment and upgrade. 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. Inglewood Residential Care Home DS0000022693.V294361.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 Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 5 (6 is not applicable). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Thorough assessments are not always obtained for people living in this home. This potentially means that people with specialist needs may receive a poor standard of care because staff at the home may not understand or be fully aware of the particular needs of the individual. EVIDENCE: A sample of four service user records were looked at during the visit. Only one service users file contained a brief assessment of their care needs. This assessment had been carried out by the service users social worker prior to admission to the home. The homes admission process includes the option for people to visit the home for the day to look around and have a meal there if they wish. Admission to the home is offered on a six weeks trial period for both the service user and the home. This helps to ensure that the home is suitable and able to meet the care needs of the resident. Most of the service users participating in the inspection said that the home had been chosen for them by a family member, following a spell in hospital or the occurrence of some other crisis. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 9 A copy of the homes Statement of Purpose was assessed during this inspection. The document did not contain all of the information necessary in order for prospective service users to make a fully informed decision about the home. Service users indicated that they had been given either a contract or details of the terms and conditions of their stay at the home. Relatives completing the comment cards indicated that they had access to inspection reports. On the day of the inspection visit a copy was not on display at the home. The home does not provide intermediate care services. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Comprehensive care needs assessments are not carried out and this potentially means that service users may not have all their needs identified and fully recorded in the care plan and places restrictions on maintaining/promoting independence and choice. EVIDENCE: The care plans kept on the files of the service users contain detailed information in respect of the persons care needs. They include the actions that staff should take to help ensure their needs are met. Due to the lack of comprehensive needs assessments it is difficult to confirm that all aspects of the health, personal and social care needs of the service user have been taken into consideration when developing individual care plans. Care plans are reviewed at least monthly and have been signed by the service user or their representative. Risk assessments have been undertaken in respect of manual handling requirements and the mobility of service users and are kept under review. Records indicate that service users have access to health care professionals such as their GP, district nurses and chiropodists. Discussions with service users and staff confirm this. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 11 There are policies and procedures at the home in respect of the administration of medication. There is also a policy and an assessment process for service users to manage their own medications if appropriate. At the time of the inspection visit there were no service users responsible for their own medication. There was no evidence to confirm that service users had been given a choice in this matter or that they had been assessed. The manager said that she preferred the home to be responsible for all medication because of the possible consequences. Records of medications coming into and going out of the home are maintained. Samples of medication record sheets were looked at during the inspection. They were generally fully completed and accurate. Some medication had been prescribed for ‘as and when’ the service user needed it. There was a choice of 1 or 2 tablets to be given at any one time, the number of tablets given had sometimes, but not always been recorded on the chart. The medication records are hand written and include the name of the medicine, dosage, strength, dates, the name of the service user, their room number and the name of their GP. Medication is supplied in NOMADs direct from the pharmacy each week. The boxes also have a photograph of the service user to aid identification. The home does not have a separate fridge for medications requiring cold storage. The manager said that it was not very often that this type of medication came into the home - occasional eyedrops or antibiotics. The arrangements were that the medicine would be stored in the domestic refridgerator in a separate box. All medication at the home was found to be stored securely on the day of the visit. The security of medication when stored in the fridge requires attention. During the visit staff were seen assisting and chatting to people living at the home. Service users were treated respectfully and staff were mindful of their privacy. Staff knocked on doors before entering rooms and service users were able to see their visitors in their own rooms or in one of the communal areas. Some of the rooms were waiting for new curtains, which were not quite ready in the short term, the manager had ensured that the windows could be covered over when the service users wanted privacy. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not provided with or encouraged to participate in social, recreational or cultural activities. The lack of detailed assessments potentially limits the autonomy and choice of the people living in the home. EVIDENCE: On the day of the inspection there were no activities available apart from the television. Some service users entertained themselves by reading or talking to other service users. Discussions with staff, service users and questionnaires returned from visitors to the home, confirmed that very few activities take place inside or out of the home. People living at the home rely on their relatives and friends to take them out. Staff at the home indicated that activities such as board games and card games had been tried but that service users did not seem interested. The manager had organised themed parties at Christmas, Valentines Day and Bonfire Night. The residents families are also invited to these parties. Relatives, friends and service users all said that visits to the home could be made at any time and that they were always made to feel welcome. People living at the home are able to choose to see their visitors in either in their own rooms or in one of the communal areas. There is a telephone at the home for Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 13 use by service users. The phone is in the main hallway and is not really suitable for phone calls that need to be made in private. People living at the home are not always encouraged to exercise choice and control over their lives. Service users had not been assessed with regards to the administration of medication and were not given the opportunity or encouragement to be responsible for their own medications. Records of food choices indicate that service users may not always be consulted about what they would like to eat. There is a bath rota in operation at the home. During the inspection visit service users were asked if they could bathe at a different time if they wanted to. Their reply was well I expect so, Ive never asked. One service user liked to have their bath on a set evening as they know they will always get the same care worker helping them. Service users said that the food was usually fairly good and that they were reasonably happy with it. On the day of the inspection the main meal at lunchtime had been freshly cooked and included fresh vegetables, service users were given a reasonably sized portion and an alternative meal was available (salad). The home does not provide a nutritionally balanced diet. Analysis of the ‘menus’ supplied by the manager indicate that there is a poor and limited variety of meals, limited choice in alternatives and poor options at the main mealtime of lunch. Fruit and vegetables do appear on the menu daily but chips, eggs cheese, cakes and ice-cream are present in high proportions. Three meals are offered each day. Breakfast is flexible depending on what time the individual gets up, times for lunch and tea are more formal and most of the people living in the home meet together in the dining room at these times, although there is the option of having meals in their own rooms if they wish. Mid morning and afternoon drinks and snacks were offered. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living at the home are not always protected by some of the practices at the home and the out of date policies and procedures in relation to adult protection. Complaints and comments are not always listened to and acted upon. EVIDENCE: A copy of the complaint process is included in the Statement of Purpose. A copy of the process is given to service users on their admission to the home. The complaints process is incomplete. There are shortfalls in its content regarding who to complain to, how to complain or what can be expected to happen if a complaint is made or that they may contact CSCI at any stage of the process should they wish. Comment cards and discussions with people living at the home indicate that people know who to direct their comments or complaints to. No one participating in the inspection had made a complaint. Discussions with service users confirmed that they would speak to the manager if they had any concerns. Service users and their relatives indicated that they thought the manager would act upon their comments or complaints, although this has not been the case regarding staff smoking near the dining room as this unacceptable practice continues with the managers knowledge. The manager at the home indicated that there had not been any other comments or complaints recently. A complaints record is not kept by the home. The keeping of such records would assist the manager to identify and act upon any recurring problems that may have been identified by the people Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 15 living at the home. Minor issues such as items of clothing not being returned from the laundry, were dealt with by the manager straight away and were not recorded. The home has policies and procedures in relation to the protection of vulnerable adults. Although records indicate that these documents have been regularly reviewed, no changes have been made since 2002 and there is a lack of awareness within the management of the service of the latest regulations, results of enquiries or external guidance. The procedures do not refer to the Protection of Vulnerable Adults register (POVA) or the local authoritys multidisciplinary procedures for dealing with allegations of adult abuse. The majority of staff at the home have received training in the protection of vulnerable adults but there are gaps in the recruitment process operated by the home, which may leave service users at risk of being cared for by unsuitable people. Staff supervision records indicated that staff are reminded of the procedures to follow should they need to help service users with their finances and the importance of record keeping, particularly where shopping has taken place. The home is not generally responsible for the management of service user’s personal allowances. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not always clean and hygienic and this potentially places service users and staff at risk from infection. EVIDENCE: At the time of the inspection visits the communal rooms at the home were generally clean. One corridor did have dirty cups, glasses and laundry left about. The home does not have a programme of routine maintenance and renewal. However, several rooms have just been fitted with new carpets and curtains were also being replaced. The people living in these rooms were very pleased with the improvements. Nineteen of the rooms have en-suite toilets and washbasins. The kitchen was found in a generally tidy condition. Inspection of the fridges and food storeroom at the home identified that these areas required a thorough clean and tidy up. Opened packets of food products were not Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 17 resealed properly or labelled and dated. This was found to be the case again on a second visit to the home a week later. The fire officer has recently visited the home and had identified one issue that needed attention. The owner of the home was in the process of seeking technical advice from the local fire officer on the best way to proceed. Again on the second visit to the home a pressure-relieving mattress obstructed a fire exit. The manager was asked to remove the obstruction straight away. The two large communal lounges are furnished and decorated to a high standard. They are warm, bright and cheerful. A conservatory area at the home is currently used as the smoking area for people living at the home. This room requires some upgrading to the decoration and furnishings in order to bring it up to the standard of the other communal areas. There are handrails throughout the home on the stairs and corridors to assist service users to get around the building safely. There is a passenger lift to the upper floors and a stair lift from the first floor to the second floor. Bathroom and toilet doors are not marked to identify such facilities. Bathrooms and toilets are equipped with aids and adaptations to assist service users to use them but there are no call bells in the bathrooms. The baths are heavily stained and the bathrooms are in need of replacement fixtures and fittings. On both visits to the home these areas were not found in a particularly clean condition. Waste bins did not have lids and disposable razors were left out. This potentially causes a risk of infection and injury for people living at the home. Toiletries were also left in the bathrooms. These items should not be in communal bathrooms, it either means that they are in communal use or are personal belongings, which should be held within the resident’s own room. A sluice room on the first floor could not be accessed as it was full of old chairs, walking frames and other rubbish and needed to be cleared out. At the time of the inspection, staff were found to be smoking in the small staff room, which is off the dining room. The door was open and cigarette smoke was detectable in the dining area. Comments have been received from visitors to the home about this problem. This was discussed with the manager. She indicated that some service users had complained about this practice. She had not done anything to prevent it and was in fact sat in the staff room at the time. The laundry appeared to be adequately equipped and a member of staff is employed to deal with the laundry at the home. The home has a contractor who deals with the disposal of waste from the home. During one of the visits, service users were sitting outside in the pleasant garden enjoying the sunny afternoon. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff have been employed at the home without the proper checks being made. This compromises the safety of people living at the home. EVIDENCE: There is a recruitment and selection policy and procedure in place at the home. This has been reviewed regularly but has not been changed or updated since 2002 in line with changing legislation, practices and requirements. Staff recruitment records show that the manager does not always follow the procedure at the home. The recruitment procedure needs to be updated to include the provision of Criminal Record Bureau checks and Protection Of Vulnerable Adult list checks together with the obtaining of two references prior to employing the new member of staff. This was discussed with the manager and guidance was given to her in respect of these important checks. Application forms need to be reviewed and updated to enable prospective staff to provide full employment histories and the names and addresses of two people who can provide references for them. Carrying out these checks will help to ensure that suitable people care for the people living at the home. The home has a low staff turnover and a large proportion of the staff have worked at the home for several years. Four staff files were selected as a sample. Staff had completed application forms, attended interviews and received some or all of their induction training on the same day. Employment histories had not always been completed or Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 19 obtained from the applicant. Two of the files contained written references (verbal references had also been obtained in one case). One file did not contain any references at all. There was no evidence on the files to confirm that the persons identity had been checked nor were there any photographs of staff on file. Staff had received induction training, recorded as taking place over one or two days. There are many topics to cover in the induction training. The time taken to carry out this training does not indicate that it meets the National Training Organisations specifications. The home does not have a training and development plan. There is evidence of some training being undertaken by staff. The manager carries out some internal training with staff, including manual handling. The manager indicated that she is a manual handling trainer but has not undertaken a refresher course for some time to up date her skills. This was discussed with her during the inspection and she was advised to obtain an update. Some staff have gained accredited training awards. Examples include First Aid, National Vocational Qualifications (NVQ) in care and adult protection. At least 50 of the staff working at the home have gained an NVQ qualification. Medication training had been carried out in conjunction with a local college. The head of the home has completed the Registered Managers Award and is looking to commence NVQ 4 in Care at a later date. There were sufficient numbers of staff on duty to meet the care needs of the service users on the day of the inspection, although the cook was off and one of the carers covered this duty too. The home did not have domestic staff at the time of the inspection. The manager was looking to appoint a new person to this role. Service users and relatives indicated that there was enough staff on duty to attend to their needs. Complimentary comments were made about the manager and the staff. One relative was spoken to at the home. They indicated that they were very satisfied with the care that their relative received. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Health, safety and hygiene standards are not consistently followed and maintained. This potentially compromises the safety at the home and the health and safety of the people living at the home. EVIDENCE: The manager at the home has gained the Registered Manager’s Qualification and has many years experience of managing residential care. The manager is also responsible for some aspects of staff training. The manager needs to update her manual handling trainer’s qualification. Staff at the home said that the manager was very supportive and encouraged them to participate in various training courses. Staff also indicated that the manager often worked alongside them in the care home. Individual supervision and appraisals take place, but not as frequently as they should. Supervision sessions are often Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 21 used to provide brief training sessions for staff, from the manager in various subjects including manual handling. The fire alarms and fire equipment are tested and checked at appropriate intervals and records of these checks are kept. Staff complete fire awareness training and this is updated at various intervals. Ten members of staff hold the Appointed Persons First Aid Certificate. This helps to ensure that there is a qualified first aider available on each shift. There are policies and procedures at the home to help ensure that the manager and staff at the home comply with health and safety legislation. The manager ensures that any accidents are recorded and notifications are sent to the Commission as required. Policies and procedures at the home had been reviewed regularly. A sample were looked at during the inspection process. They were found to need updating in the light of changes to legislation and current practice. The refridgerators and store cupboards in the kitchen required cleaning and tidying up. Opened packets of food were not re-sealed properly nor labelled and dated. Several packets of cooked meat in the fridge were out of date and the manager was advised to check the dates on all of the food in the fridges. Bathrooms were also found to be in an unhygeinic condition. Gas and electrical safety certificates were not available at either visit. A letter has been received from the proprietor stating that gas boilers have been checked and need some repair. The proprietor is in the process of obtaining estimates for this work. The electrical wiring check is to be carried out in July. The home has procedures for the safe keeping of service users money and valuables. At the time of this inspection the home was not responsible for the management of service users finances. All financial affairs and personal allowances were handled by the service users families. The home does not have an annual development plan based on a systematic cycle of planning - action – review and matters relating to the environment at the home are mentioned elsewhere in this report. The manager asks people living in the home and visitors to the home to complete satisfaction surveys. Any issues that arise from the survey are said to be dealt with by the manager. An annual report is not produced and staff at the home are not included in the survey, although the manager said that staff would let her know if there were any issues. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 22 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 2 3 2 X 3 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 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X 2 3 X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 4 Requirement Timescale for action 31/07/06 2 OP3 14 3 OP7 15 4 OP9 13 (2) 17 (1) (a) The registered person must review and update the Statement of Purpose to ensure that the document includes all of the information detailed in Regulation 4 and Schedule 1 of the Care Homes Regulations. The manager must ensure that 31/07/06 the needs of the service user have been assessed by a suitably trained and qualified person or a copy of the assessment has been obtained prior to the person being admitted into the home. The manager must ensure that 31/07/06 each service user has a plan of care, which is generated from the comprehensive care needs assessment, sets out in detail the action which needs to be taken by care staff to ensure that all the needs of service users are met. The plan must be drawn up in consultation with the service user or their representative and kept under regular review. The registered person must 31/07/06 ensure that where medicines DS0000022693.V294361.R01.S.doc Version 5.2 Inglewood Residential Care Home Page 24 5 OP9 13 (2) with a variable dose are administered, for example “one or two tablets”, the dose actually given, is accurately recorded on the MAR sheet. The registered person must ensure that medicines requiring cold storage are kept in a locked fridge, separate from foodstuffs, and the temperature must be monitored on a daily basis. The manager must consult service users about their social interests and make arrangements to enable them to or maintain their contacts and social activities within the community. The manager must also consult service users about the programme of activities arranged by the home and provide facilities for recreation, including having regard for the needs of the service users. The registered person must develop written menus for at least a three weekly cycle. The record must contain sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. Service users must be consulted regarding the content of the menus. The manager must ensure that the home has a robust complaints process. The procedure must be clear and accessible to people using this service and contain all of the information as detailed in Standard 16 and Regulation 22 on the National Minimum Standards and related Regulations. The registered person must ensure that service users are DS0000022693.V294361.R01.S.doc 31/07/06 6 OP12 OP14 16 (2) (m) (n) 31/08/06 7 OP15 16 (2) (i), Schedule 4 (13) 31/08/06 8 OP16 22 31/07/06 9 OP18 13 31/07/06 Page 25 Inglewood Residential Care Home Version 5.2 10 OP19 23 11 OP21 23 12 OP26 16 (2) (j) (k) 23 (2) (d) 13 OP29 19 safeguarded from abuse. Robust policies and procedures must be developed and include up to date information in relation to legislation, POVA, multi-agency working and good practice. Staff at the home must be made aware of the home’s revised arrangements regarding adult protection. The registered person must develop a maintenance plan for the up grading of the home including the conservatory, bathrooms, gas appliances and electrical rewiring. Timescales for action must be included in the plan. The registered person must ensure that toilets and bathrooms for use by service users are clearly marked as such. The registered person must ensure that all areas of the home are kept clean and hygienic. Systems must be in place to control the spread of infection in accordance with relevant legislation. Alternative arrangements must be made for staff that wish to smoke. The manager must ensure that there is a robust recruitment and selection process at the home that meets the requirements of legislation. Staff must not be appointed or confirmed in post until satisfactory checks (CRB and POVA) and references have been obtained. The registered person must ensure that there is a training and development plan, which meets National Training Organisation workforce training requirements. This must include DS0000022693.V294361.R01.S.doc 30/09/06 31/07/06 31/07/06 31/07/06 14 OP30 18 30/09/06 Inglewood Residential Care Home Version 5.2 Page 26 15 OP31 10 16 OP33 24 17 OP36 18 (2) 18 OP38 12, 13, 16(2)(j) (k) comprehensive induction and foundation training. The registered person must ensure that her knowledge, skills and competence are kept up to date with periodic training. The registered person must ensure that a system is established and maintained for reviewing and improving the quality of care provided by the home. The registered person must ensure that staff receive formal supervision at least six times per year. The registered person must ensure that the health, safety and welfare of service users and staff are promoted and protected. 30/09/06 30/09/06 31/07/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP27 Good Practice Recommendations Domestic staff should be employed in sufficient numbers to ensure that the home is maintained in a clean and hygienic state. Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Inglewood Residential Care Home DS0000022693.V294361.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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