CARE HOMES FOR OLDER PEOPLE
Irene House 1 Parkfield Road Worthing West Sussex BN13 1EN Lead Inspector
Miss Helen Tomlinson Unannounced Inspection 5th January 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 Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Irene House Address 1 Parkfield Road Worthing West Sussex BN13 1EN 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) 01903 529060 01903 529058 Guild Care Mrs Patricia Hall Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: Irene House is a care home registered to accommodate forty residents over the age of sixty-five years, some of whom may have nursing needs. The home is situated in a residential area of Worthing. It is a detached, two-storey building with a central courtyard area and private parking facilities at the front entrance. Residents are accommodated in single rooms with a wash hand basin. Two bedrooms have en-suite toilet facilities. There is a passenger lift for access from the ground floor to the first floor. There are three lounge areas and two dining rooms. Irene House is owned by Guild Care, an organisation which has three other care homes in the area. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspector arrived at 10.30am and left the premises at 6.30pm. The manager was present for most of the day. The inspector spoke with eleven residents either in their own bedrooms or in the communal lounges. They discussed their experiences of life in the home. Five visitors and eight members of staff were spoken with. A tour of the premises took place. Care records and other documentation was examined. At the time of the last inspection an issue of grave concern was noted, regarding the hazardous storage of equipment and other items in the home. This also impacted on the fire safety since fire doors could not be closed because of the way items were stored. An immediate requirement was issued during that inspection and the matter was corrected within three hours. At this inspection this issue had been resolved and all items were stored safely with no hazards to residents present. Following the last inspection nine statutory requirements and seven good practice recommendations were made. At this inspection much improvement had been made in the home and staff and management had worked hard meeting eight of the nine requirements. Several residents commented on favourable changes within the home. These included improvements in the decoration and cleanliness of the home, a more stable staff team and complimentary comments about the manager who had been in post approximately six months. Following this inspection four requirements and six good practice recommendations were made. What the service does well:
The home was clean, warm, tidy and free from offensive odours. Residents and visitors commented that the home was always clean and this seemed to have improved over the past few months. Residents said they liked the staff, who they described as “helpful, polite and kind”. They were complimentary about the manager, who had been in post about six months, saying they could approach her with any issues or comments and she was making some positive changes. Residents said they could choose when to get up and go to bed, where to sit during the day and whether to eat their meals in their own rooms or the communal dining room. Some of the resident’s files contained information regarding the resident’s preferences. The correct procedure to protect the vulnerable adults at the home had been followed, when an incident between two residents had taken place. The manager and staff at the home had involved other agencies to make sure all residents in their care were protected. Staff said there were good opportunities provided for a variety of training, which was relevant to their job. They were given all statutory training, with
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 6 timely updates, and additional pertinent training regarding specific issues was provided. A thorough system of quality review was provided by the organisation which owns the home. This included consultation with residents, staff and visitors, external and internal audits and spot checks by people not directly involved in the day to day running of the home. What has improved since the last inspection? What they could do better:
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 7 The health care assessments available should be completed for all residents, as soon as possible following admission to the home. These must result in a detailed plan of care and management. Pressure sore prevention plans were not present for residents who had been assessed as being at high risk. These must be recorded and implemented to make sure pressure sores are prevented. The documentation for recording wound care and dressings had been reviewed but remained unclear. Some out of date records were kept in files with current information. The Registered Nurses did not have adequate time to carry out the nursing tasks, oversee the care of the more dependant residents and make sure the records were up to date. This resulted in the reviews of some care plans being out of date, some not containing adequate information and a lack of time to work with the care assistants to ensure the best care was given to the more dependant residents. The manager stated a recruitment drive for qualified nurses had resulted in the employment of two new ones, but they had not yet started work. It was discussed that in the meantime the nursing care must be kept up to date. Some of the bedrooms in the home presented restricted space for the equipment needed for some residents. A risk assessment of the moving and handling and safety issues this may present should be completed for the more dependant residents, and those who require specialist equipment to be provided. Staff did not receive frequent supervision by their senior. This should be done, at least six times per year, and provide an opportunity for both parties to discuss any issues or concerns. Adequate bathing facilities should be provided to meet the needs of the residents. The inspector was informed that one of the bathrooms, currently used for storage, was to be converted to a level access shower. This should be carried out as soon as possible and the Commission notified of the expected timescale. Currently resident’s money is paid into a Guild Care bank account. This is set up purely for the resident’s money and is not used for other purposes. However, residents own money must not be paid into any bank account, unless that account is in their own name. 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. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4. Residents had a written contract which laid out the terms and conditions of their accommodation and services offered. Residents were not admitted to the home without a suitably qualified person having carried out an assessment of their needs. EVIDENCE: A copy of the contract provided for residents was seen. This contained all relevant information for the resident about the terms and conditions of their stay in the home. These were signed by the resident and a representative of the home. The manager discussed that all prospective residents were seen and assessed, usually by her, prior to being admitted to the home. This was evident from the file of one resident who had become accommodated at the home on the 20th December 2005 and had been seen in hospital, by the manager, on the 19th December 2005. This assessment covered all aspects of the person’s care needs and how these were to be met. The manager discussed that the current residents, the rooms available and the skills of the staff were all taken into account before a place was offered to a prospective resident. In this way the residents were assured that the home could meet their needs.
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 11. All residents had a plan of care. These were not kept up to date and did not contain the action required to meet all the identified needs. The resident’s health care needs were met. Some aspects of health care were not adequately documented. The issues identified at the last inspection with regard to storage and disposal of medication had been resolved and this was safe. Staff treated residents with sensitivity and respect at the end of their lives. EVIDENCE: Since the last inspection the new documentation for the care plans had been implemented. This gave a more thorough way of recording the residents assessed needs. Not all this documentation was fully completed for the residents receiving nursing care. For those residents receiving personal care the documentation gave a more detailed picture of their lives, needs and how these were to be met. Since the last inspection the practice of storing the care plans in the individual resident’s bedrooms had begun. This made them more accessible to the residents and their representatives, who were included in their care, should they wish to do so. The care plans seen had not been reviewed since October 2005. In some instances this made some of the plan out of date with the current situation.
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 11 Assessments to identify the resident’s individual health care needs included, moving and handling, wound assessments and the risk of development of pressure sores. These formed the basis for the plans of care which were documented. At the last inspection not all risks or needs identified by assessment had a corresponding plan of care. This remained the case at this inspection with residents being identified as at high risk of developing a pressure sore having no plan of how this should be prevented. This must be present for all residents who are identified as being at risk. For one resident who was displaying some aggressive behaviour towards the staff, no plan of management, to provide a consistent approach, was documented. Falls risk assessments had been completed where a risk of falls was documented. Some residents had a nutritional risk assessment completed. Where this indicated problems with eating and drinking no specific plan to meet these needs had been documented. For one resident, who had a high risk of pressure sore development and was diabetic, no nutritional risk assessment had been completed. Since the last inspection some work had been undertaken, with the care assistants, to help them understand the need for good nutritional and fluid intake in older people. This had resulted in residents being assisted with fluids more frequently, as evidenced by the daily charts used. Although this had improved there were some instances when drinks were left out of resident’s reach and the necessary assistance was not given. The wound charts had been reviewed since the last inspection. Some practices had changed which the nurses said had improved the care of wounds for the residents. Some charts remained confusing and contained conflicting information. It was discussed that this documentation needed further review. It was discussed with the nursing staff and manager that whilst there was some improvement in the documentation of the health care needs of the residents and how these were to be met, there were still issues of lack of appropriate assessments and plans for some individual needs. The care plans for the residents receiving personal care provided a good picture of the resident’s needs, wishes and choices. The social and emotional aspects of their care were included, which was not present for the residents receiving nursing care. A requirement made at the last inspection that all bed rails have protectors fitted had been met. At the last inspection there was a requirement made that wasted medication was not stored in unlabelled bottles. This practice had ceased and a contract was in place for the safe and correct disposal of waste medication. On examination of the medication administration sheets there were some gaps where nurses had not signed when medication had been administered. All qualified nurses must work within their own code of practice regarding documenting medication administration. Staff spoke about residents who had passed away with genuine fondness. They showed an understanding of other residents and relatives feelings at this sad time and the need to be respectful of others views and wishes. The individual wishes and choices of the residents, in the event of their death, were
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 12 recorded on the majority of care plans seen. This is important to make sure the individual’s wishes are respected at this time. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 13 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): 13 and 14 Residents were assisted and encouraged to maintain contact with family, friends and the local community, should they wish to do so. Residents were helped to maintain control over their lives and make choices about their day to day routine. EVIDENCE: Visitors were seen in the home, at various times of the day. They were assisted to see their relatives in their own bedrooms or the communal rooms, as they wished. Some visited at a time when they could be included in their care, should they wish to do so. Visitors said they were welcomed into the home, that staff were very friendly and kept them informed of any changes in their relative’s condition. Residents were assisted to keep contacts in the local community, visiting friends and family, as they wished and were able. Residents said their choices were understood and respected by the staff in the home. The resident’s preferences about their daily routine and how they would like to be cared for were included in some care plans. Documentation for this was available on which could be recorded the residents most important life events, people and places, along with rising and retiring times, social expectations and patterns of living. Residents spoken with said the routine of the home met with their choices and they were consulted about change. Information about contacting an independent advocacy service was available on the notice board.
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 Residents were aware of how to raise concerns or complaints. They were satisfied that they would be listened to. Residents were protected from abuse. EVIDENCE: A record of complaints or concerns brought to the manager’s attention was kept. Nothing was recorded since July 2005. Residents spoken with said they would approach the “new manager” with any concerns they had and felt sure they would be listened to and action would be taken. Those residents who had had cause to raise any concerns had done so with staff and said they had been resolved quickly and to their satisfaction. Prior to this inspection the manager had taken appropriate action when an incident between two residents had taken place. The necessary agencies had been involved and all residents were protected. Staff had received training regarding the protection of vulnerable adults. The policies and procedures in the home met with the West Sussex guidance. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24 and 26 Residents benefit from living in a well maintained, clean and tidy home. Varied communal spaces, both inside and out, are available for residents to use if they wish. There are sufficient lavatories to meet the needs of the residents. Due to a change in use of two bathrooms, to storage areas, additional bathing facilities are required. The equipment necessary to meet the resident’s needs was provided by the home. The resident’s bedrooms appeared comfortable, with their own possessions present. Some bedrooms have limited space available and may not be suitable for residents with specialist equipment. The home was clean and staff were aware of necessary practices to prevent the spread of infection. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 16 EVIDENCE: At the time of the last inspection there were grave concerns regarding the storage of equipment and other items in the home. This presented a risk to the safety of the residents and staff. Due to this haphazard storage many fire doors were propped open or could not be shut because of the amount of equipment in the room, spilling into the corridor. This was temporarily resolved at the time of the inspection, by closing off two bathrooms to residents and using those for storage. At this inspection all equipment and other items were stored safely. There was no hazard presented to the residents by the storage of items in the home. All fire doors were closed throughout the inspection. This improved the overall impression of tidiness in the home and safety for the residents and staff. Since the last inspection some redecoration had been completed. This included the corridors, communal lounges and dining room. These areas were much improved, looking brighter and cleaner. The residents commented saying they were “much better” and it was “nicer to eat in the dining room.” New dining room furniture had been installed also. The balcony railings outside two first floor bedrooms had been made taller to reduce the risk of falling. This met with the guidance of the local environmental health officer. Residents commented on the cleanliness of the home, saying it had improved over the past few months. All areas of the home were clean. Appropriate hand washing facilities were present and staff were seen to use protective clothing correctly. Staff had received training on the prevention of the spread of infection. The indoor communal areas consist of two lounges, a seating area close to the main entrance and office, one small dining area and a large dining room. The outdoor space includes a garden to the side of the house and a paved courtyard in the middle. At the time of this inspection gardeners were present drawing up plans for refurbishment of this courtyard area. There were sufficient numbers of lavatories, close to the communal areas and bedrooms. Commodes were provided in resident’s bedrooms where necessary. Due to the change in use to storage, two bathrooms were no longer accessible to the residents. It was discussed at the last inspection that this could not remain the case, as it reduced the number of available bathing facilities to only two assisted baths. A level access shower unit is planned to replace one of the baths on the ground floor. Work on this had not begun at this inspection and a timescale for completion should be sent to the Commission. All bathrooms and toilets were clean, in good repair and provided raised toilet seats and handrails to assist the residents. Other equipment available included hoists, other moving and handling equipment e.g. slide sheets, grab rails and specialist chairs. Since the last inspection several new armchairs and specialist nursing recliner chairs had been purchased. The residents using these said they were comfortable and they felt safer in them. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 17 The bedrooms seen had all been personalised, by the residents, who had included their own pictures, photographs and furniture. Some bedrooms have a limited amount of space and the layout could be awkward for the use of moving and handling equipment. In some bedrooms furniture had to be moved each time a hoist was used. A discussion took place with the manager that the size and layout of rooms used by the residents must be suitable to meet their needs. Risk assessments for the safe use of equipment in bedrooms should be carried out and measures taken to reduce the risk of injury to staff and residents. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 and 29 There were sufficient care staff on duty to meet the needs of the residents. The number of nursing staff on duty was not sufficient to meet all the resident’s health care needs, complete the documentation and provide direction to other staff. Resident’s benefit from well trained staff. The recruitment procedures had improved since the last inspection, however not all necessary information was present. EVIDENCE: The numbers of care assistants, over a twenty-four hour period, was sufficient to meet the needs of the residents. Staff and residents said they felt the numbers were adequate. The use of agency staff had reduced overall since the last inspection, although there had been a period of high usage over the Christmas period. Some residents said they felt there was a better consistency of staff with “more familiar faces” now looking after them. The manager confirmed that the permanent staff team had increased. There was a discussion with the qualified nurses, and the manager regarding the hours available when two nurses were on duty. This had reduced since the last inspection, although the recent recruitment of two new nurses would help this in the near future. There was evidence that the nursing staff were unable to review the care plans and health assessments of the residents frequently enough and were unable to work alongside the care assistants to provide support and training. This was due to the number of highly dependant residents accommodated in the home. This was of particular concern when the manager was not on duty and the nurse was the person in charge of the home.
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 19 The provision of time for the qualified nurses should be reviewed and be appropriate to meet the needs of the residents. At the last inspection a requirement was made regarding the recruitment of staff and the gathering of all necessary information, including any gaps in employment. At this inspection this had improved, but not all gaps in employment were explored in the staff files seen. The manager confirmed that all staff had received satisfactory CRB and POVA checks prior to employment. Evidence that these checks had been carried out was on file. Two written references were present in the staff files seen. Staff spoken with said they received good training from Guild Care. They had completed the statutory training such as moving and handling, health and safety, abuse and neglect and food hygiene. They had annual updates and spoke highly of the quality of the training provided. They had the opportunity to attend training on specific topics, such as dementia care and nutrition. They said that whenever possible, if they were working with a more experienced member of staff, their knowledge would be shared. There was a rolling programme for staff to complete their NVQ training, with many having already achieved the NVQ 2. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 and 36 The home is run and managed by a suitably qualified, experienced and competent person. Residents and staff spoke highly of the manager who had been in post only six months. The home is run in the best interests of the residents, with good internal and external quality checks in place. The current procedures do not safeguard the individual finances of the residents. Staff do not receive adequate supervision from their line managers. EVIDENCE: The manager of the home is in the process of registering with the Commission. She had been in post, as the manager, for approximately six months. Prior to this she had managed and owned her own care home and has twenty-two years experience working with older people. She is a qualified Registered General Nurse and keeps herself updated with training courses and Internet information.
Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 21 There are a number of methods in place to check the quality of care provided in the home. These include audits and spot checks carried out by Guild Care staff from head office, visits by trustees of the charity, surveys of the opinions of staff, residents and visitors. One resident is on the committee of trustees as a representative for the residents in the home. Residents said they felt they could talk to the manager or any other member of staff if they were not happy about any aspect of care in the home. Staff, residents and visitors said there were informal ways of feeding back to the staff, giving both praise and raising issues. Monthly reports on the quality of various aspects of care, services and facilities are made and a continuous programme of improvement drawn up from this. Some personal monies for most residents are kept centrally at the home. The organisation has an accounting system set up on the computer. Records were kept of the individual residents money and receipts were produced. The resident’s personal money was pooled together and the amount kept in the home was not the same as that shown in the records. Some was held in the bank account of the organisation until the individual requested it. It was discussed, with the person in charge, that this did not meet the regulations and no money must be kept in a bank account, unless it is in the name of the resident. One to one supervision of staff was not conducted on a regular basis. It was discussed that this should be done, at least six times per year, to give both parties opportunity to discuss aspects of practice, training and any other issues which either party wished to discuss. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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 x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 3 x 2 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 2 x x Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? 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 Timescale for action 31/08/05 2. OP21 23(2)(j) 3 OP27 18(1)(a) 4 OP35 20(1) All residents must have a plan of care drawn up in consultation with them, where possible, and kept under review. These must include all aspects of health care as assessed by the nursing staff e.g. pressure sore prevention. This requirement remains unmet since the inspection of 3/8/05. The timescale given of 31/8/05 has expired Adequate numbers of bathing 31/01/06 facilities must be provided. The Commission must be informed of the timescale for the conversion of the ground floor bathroom from storage to a level access shower. The number of qualified nurses 31/01/06 working in the home should be reviewed to make sure the needs of the residents are met at all times. The registered person shall not 31/03/06 pay money belonging to a resident into a bank account unless the account is in the name of the resident to which
DS0000024160.V276552.R01.S.doc Version 5.1 Irene House Page 24 the money belongs. 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. 4. 5. 6. Refer to Standard OP7 OP8 OP8 OP24 OP29 OP36 Good Practice Recommendations All risks and needs identified should have a plan of management documented Wound charts should be kept up to date and clearly documented All health care needs should be assessed. Risk assessments to make sure the size and layout of the rooms are suitable for the needs of the resident, should be carried out. All gaps in employment should be explained and a full employment history documented. Supervision should take place, with all staff, at least six monthly. Irene House DS0000024160.V276552.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Irene House DS0000024160.V276552.R01.S.doc Version 5.1 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!
