Inspection on 10/07/06 for Jeian

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Jeian 07/01/08

Jeian 09/07/07

Jeian 10/01/06

Jeian 05/09/05

Jeian 29/11/04

Jeian 14/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Jeian Jeian Care Home 322 Colchester Road Ipswich Suffolk IP4 4QN Lead Inspector Tina Burns Unannounced Inspection 10th July 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jeian DS0000047113.V301867.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. Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jeian Address Jeian Care Home 322 Colchester Road Ipswich Suffolk IP4 4QN 01473 274593 01473 274593 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 Felix Emejulu Chukwuma Mr Felix Emejulu Chukwuma Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Jeian residential home is a care home registered for up to ten older persons. It is situated on the corner of several main roads in a suburb of Ipswich and close to Ipswich hospital, several local shops, bus routes and other amenities. All bedrooms are fully furnished single bedrooms. The main lounge area leads off the main corridor and is adjacent to a sitting/dining area situated in the veranda. There is an emergency call bell system in operation in each bedroom, toilet and bathroom. The home is currently owned by Mr Felix Chukwuma who took ownership of the home at the end of October 2003. He is also the Registered Manager. Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced, key inspection that took place on a weekday between the hours of 11.00am and 5.00pm. The inspection focused on the core standards relating to care homes for older people and the report has been written using accumulated evidence gathered prior to and during the inspection. The inspection process included a tour of the premises and grounds, examination of three service users records, and examination of a range of policies, procedures and records. Information was also collected from the home’s pre inspection questionnaire. The inspector also spoke with seven residents, the cook, three care workers and a team leader. Further information was received from a return of ten service user surveys and ten relatives/visitors surveys. The Registered Manager/owner was on leave at the time of inspection, however staff on duty were co operative and fully contributed to the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Staffing levels need to improve to ensure that resident’s needs are met and residents should be consulted about the recruitment process and be able to communicate effectively with staff employed. The manager must also ensure that the home is appropriately managed in his absence. Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 6 The home needs to evidence that a thorough and detailed risk assessment has been undertaken for the resident with bedsides in place and another resident that is ‘prone to wander’. The home must also ensure that residents with symptoms of dementia are appropriately reviewed or reassessed and the Commission is notified of any resident diagnosed with dementia. The homes complaints procedure needs to be amended to reflect the fact that the National Care Standards Commission has been replaced by the Commission for Social Care Inspection. Furthermore, abuse procedures in place must include local authority procedures for the protection of vulnerable adults. Information provided to residents/relatives concerning staff qualifications is misleading and must be amended to reflect NVQ qualifications actually held. Incident and accident records must be available for inspection at all times. Finally, the external grounds are untidy and should be appropriately maintained. Furthermore, a risk assessment must be undertaken to eliminate/minimise risks in the environment. 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. Jeian DS0000047113.V301867.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 Jeian DS0000047113.V301867.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, 4, 5 & 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective residents are able to make an informed choice about living at the home and can expect the home to carry out suitable assessments in order to meet their needs. However, residents cannot be certain that they will be able to make their needs known at all times. EVIDENCE: The home’s Statement of Purpose, Service User Guide and Certificate of Registration was on display in the entrance to the home. Service users spoken with confirmed that they each had a copy of the service user guide in their rooms. The guide outlined the objectives of the home and its overall philosophy of care and included details of the facilities it provides, information regarding terms and conditions and information about fees and charges. Fees are £331 - £375 weekly. Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 9 The records of three service users were examined and included evidence of local authority assessments and pre admission assessments undertaken by the home. The Roper, Logan and Teirney model of assessment had been used and covered twelve activities of daily living: maintaining a safe environment, breathing, eating and drinking, elimination, dressing and undressing, controlling body temperature, mobility, working and playing, expressing sexuality, sleeping and dying. There were also records of nutritional assessments; falls risk assessments and pressure sore risk assessments in place. On the whole residents spoken with were satisfied with their care and felt that their needs were generally met, however feedback indicated that communication was often an issue in terms of the high percentage of overseas workers that did not speak fluent English. On the day of inspection one of the five members of staff spoken with had English as a first language, four spoke English with varying degrees of fluency. Residents confirmed that at times this made it difficult to make their needs known. The Service User Guide stated that introductory visits are encouraged and new service users can be admitted on a trial basis, to ensure the home is suitable for their needs. The home does not provide intermediate care. Jeian DS0000047113.V301867.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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are not entirely safeguarded by their individual risk assessments, however, service users can expect to be treated with respect and have their privacy upheld. EVIDENCE: The three residents records examined included individual care plans and a range of risk assessments covering areas such as nutrition, pressure areas, falls and manual handling. However, a number of issues were identified in the records seen. Bedsides were used for one resident and whilst there was documentation in place to evidence that the GP and next of kin had agreed to the use of bedsides the residents records did not include an appropriate risk assessment. The same resident’s weight had not been monitored with the frequency required according to the care plan. Another resident who was confused and ‘prone to wander’ had strategies in place to minimise the likelihood of them leaving the building unsupervised. However, there was no Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 11 evidence of an appropriate risk assessment to reduce/eliminate risks in the immediate environment and grounds. Surveys returned and records seen evidenced that one resident had been diagnosed with mild dementia since admission to the home, however the Commission had not received notification. Further feedback from relatives/visitors and examination of records also indicated that another resident might have dementia. However at the time of inspection there was no evidence that their needs had been appropriately reviewed or reassessed. Feedback received and records seen evidenced that the home supports residents to access health care services such as, GP’s, Community Nurses, outpatient’s appointments and Chiropody. Medication was supplied to the home by a large pharmacy using a monitored dosage system and kept stored in a locked cabinet in an office area. Records seen and staff spoken with confirmed that staff with responsibility for administering medication had been appropriately trained. The medication administration records examined had been signed, dated and completed appropriately. Since the last inspection the home had invested in a medication trolley compliant with good practice guidelines. Resident’s spoken with, feedback from survey’s and observations made during the inspection indicated that residents are treated with respect and have their right to privacy upheld. Jeian DS0000047113.V301867.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 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s find that their families and friends are made welcome at the home, however options in relation to leisure activities and menu’s are limited. EVIDENCE: Service users spoken with indicated that on the whole they were able to exercise choice in relation to their life style and daily activities, however feedback from survey forms and residents on the day of inspection confirmed that at times staffing constraints placed some restrictions on residents. One resident commented “they are so busy, I don’t like to ask”. Evidence also indicated that although the home provided occasional ‘entertainment’ such as ‘sing a-longs’ and bingo, activities were limited and residents relied mainly on their friends and relatives for opportunities to ‘get out and about’. On the day of inspection five residents spent most of the day in the communal lounge watching television, others spent the majority of the day in the privacy of their own rooms. Individual’s rooms included personal furnishings and possessions Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 13 that residents had brought with them. Observations were that staff seemed to have a good understanding of the service user’s preferred routines and planned their ‘shifts’ with them in mind, however at peak times of the day residents indicated that at times they had to wait for personal assistance. On the day of inspection the inspector found the atmosphere at the home calm, relaxed and welcoming. Residents spoken with confirmed that the home always gave their visitors a warm welcome and that they were able to meet with them in the privacy of their own rooms or join them in the communal lounge or dining area. The visitor’s book and surveys returned evidenced that friends and relatives visited regularly. Observations made and residents spoken with also confirmed that they could take their meals in either of the communal areas or in the privacy of their rooms. The dining area was comfortable and suitably furnished but on the day of inspection most service users chose to eat in their rooms or the communal lounge. Residents confirmed that they were consulted about the homes menu and asked to select from a choice of two options each morning, they could also request an alternative if they wished. Comments regarding the food were mixed but overall the feedback from residents spoken with and surveys received indicated a lack of fresh fruit, vegetables and home cooked meals. Comments included “It would be much nicer if we had fresh food” and “It’s all frozen food”. Staff spoken with including the cook, confirmed that the cook was employed to work 10.00am – 1.00pm Monday to Friday to prepare a cooked dinner; breakfast, light evening meals and a cooked lunch at weekends were prepared by the care workers. Staff also confirmed that ingredients were mainly frozen, not fresh. Milk was UHT and not delivered or purchased fresh on a daily basis. Jeian DS0000047113.V301867.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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents can expect the home to listen to their complaints and concerns and take them seriously but adult protection procedures do not entirely safeguard them. EVIDENCE: The home had a complaint’s procedure in place and available to residents and visitors in the entrance to the home, however it had not been updated to reflect the fact that the National Care Standards Commission has been replaced by the Commission for Social Care Inspection. Feedback from survey’s and residents spoken with indicated that the manager was approachable. The complaints book examined indicated that there had been no complaints recorded since the previous inspection, however one complainant had raised concerns with the Commission in June 2006. The concerns received included a number of elements including concerns about staffing numbers, medication, lack of domestic and kitchen staff, quality of food, recruitment procedures and supervision and monitoring of frail/confused residents. Each of these matters have been assessed as part of this key inspection, findings are recorded under the relevant sections of this report (Health and Personal Care, Daily Life and Social Activities and Staffing). Staff records were unavailable on the day of inspection due to the absence of the manager, however staff spoken with indicated that they had received adult protection training. The home did not have a copy of the Suffolk Inter Agency Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 15 Policy and Procedures for the Protection of Vulnerable adults in place, however there was an Elder Abuse Policy in place. The Elder Abuse Policy did not reflect the fact that the National Care Standards Commission has been replaced by the Commission for Social Care Inspection; furthermore it did not adequately detail local authority reporting procedures. All staff must have access to and be familiar with the local authority procedures for reporting concerns regarding adult protection. Jeian DS0000047113.V301867.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, 20, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is generally clean and hygienic but the grounds are not entirely safe and well maintained. EVIDENCE: Feedback from residents and relatives/visitors survey’s indicated that there were often shortfalls in cleaning standards at the home. Staff on duty confirmed that domestic staff were not routinely employed and it was an expectation of the care workers to undertake cleaning and laundry tasks, most of which was carried out by the waking night staff. On the day of inspection areas seen were clean, comfortable, homely and free from unpleasant odours. Observations made, documents seen and staff spoken with also confirmed that the home had appropriate Infection Control procedures in place. Communal areas consisted of a lounge and adjacent dining area, and another small lounge area at the back of the building that ‘doubled’ as a staff sleeping Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 17 in room. Access to the grounds had some restrictions at the time of inspection due to building works being carried out. The commission had been notified that works were in progress to extend the home with the aim of increasing the number of residents. However, residents continued to be able to sit in the enclosed garden area and confirmed that they enjoyed spending time in the ‘fresh air’. At the time of inspection the garden was untidy in places particularly where an old pond area had been filled with rubble, weeds and branches. There was also no evidence that a risk assessment had been undertaken to reduce risks from potential hazards in the front drive and garden areas, for example a small pond, green house and uneven ground. An appropriate fire alarm system was in place and records evidenced that equipment was routinely tested and inspected by the manager, ‘handyman’ or contractors as appropriate. All bedrooms were single, private rooms. Bedrooms seen were all individually furnished and decorated and provided sufficient and comfortable facilities. Service users had equipped their rooms with many of their own belongings and personal effects. All bedrooms had a call system in place, and in working order on the day of inspection. Jeian DS0000047113.V301867.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The numbers and skill mix of staff do not ensure that resident’s needs are met. EVIDENCE: In June 2006 a complaint received by the Commission included concerns about staffing, further concerns were expressed in residents and relatives/visitors surveys. Comments and concerns expressed included insufficient levels of care staff, absence of domestic staff and cooks, inadequate management cover in the managers absence and insufficient numbers of staff employed speaking fluent English and able to communicate reliably with residents. Examination of the rota and discussion with staff and residents on the day of inspection identified concerns with staffing levels overall. The manager was on leave at the time of inspection, however discussions with staff on duty evidenced that there were not clear arrangements for the management of the home in his absence. Evidence also confirmed that there were two care staff on duty during waking hours (this may or may not have included a team leader), one waking and one sleep-in night staff and a cook on duty from 10.00am – 1.00pm Monday to Friday. The deputy manager was on long-term leave and had not been replaced. Bearing in mind the needs of the residents and care staff’s responsibility for domestic /laundry tasks and preparation of some meals these numbers were insufficient at peak times of Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 19 the day. Furthermore, one care worker on the early shift was a new employee (working their third shift) and was not supernumerary. In relation to the concerns raised about language issues residents spoken with confirmed that they found it difficult to make themselves understood at times. On the day of inspection one of the five members of staff spoken with had English as a first language and four spoke English with varying degrees of fluency, more significantly conversation indicated that their ability to understand local dialects/spoken English varied and was not consistently high. Staff records were unavailable on the day of inspection due to the absence of the manager. However staff spoken with and the recruitment policy seen indicated that appropriate recruitment procedures take place. However, the standard relating to recruitment will be assessed in more depth at a future inspection. Staff spoken with confirmed that all new staff undertake TOPPS training as part of their induction programme. They also confirmed that the home provides core skills training such as manual handling, fire safety, medication and food hygiene. The homes Pre-Inspection questionnaire indicated that seven of the eleven staff employed had completed NVQ 2 or above but this could not be verified without access to staff files. The homes notice board indicated that the member of staff leading the late shift was NVQ 2 qualified, however conversation with them confirmed that the care worker did not hold an NVQ qualification. Jeian DS0000047113.V301867.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, 32, 33, 35, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents can expect to find the manager approachable and competent. However, residents cannot be certain that their health, safety and welfare is promoted and protected. EVIDENCE: The proprietor is also the homes Registered Manager. Both he and the deputy manager were on leave at the time of inspection. At the last inspection the manager confirmed that he was in the process of undertaking the Registered Managers Award, the assistant manager had completed National Vocational Qualifications in care (levels 2 and 3) and care management (level4). Staff and residents confirmed that they found the manager competent and approachable. Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 21 The home had a quality assurance policy in place that included reference to annual development plans, residents and relatives surveys, annual policy reviews and CSCI inspections. Staff and residents confirmed that the manager consulted them regularly on matters affecting the home. Views of residents and their relatives are also welcomed via the homes ‘suggestion box’ positioned in the ground floor hallway. Evidence of Quality Assurance audits undertaken will be examined at a future date. The homes Pre-Inspection questionnaire confirmed that all residents maintain control of their own finances, with the support of their families where appropriate. Health and safety records indicated that the home had appropriate Fire precautions in place and water temperatures were now being maintained close to 43 degrees centigrade. Staff spoken with and the homes pre inspection questionnaire indicated that the local authority fire services had recently undertaken an inspection of the premises but the report was outstanding at the time of the inspection. Records also confirmed that Ipswich Borough Council had undertaken a health and safety inspection in May 2006 that had resulted in two requirements in relation to ensuring the risk of Legionella bacteria is minimised. The manager’s progress in this matter will be explored at a later date. Examination of the homes induction procedures and discussion with staff indicated that the home provides appropriate training in relation to health and safety, fire safety, and manual handling. On the day of inspection staff on duty were unable to locate the homes incidents and accidents records. Consequently, the inspector was unable to identify the number and nature of any incidents. Jeian DS0000047113.V301867.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 3 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 X X X 3 X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? See 7 below 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 2 Standard OP27 Regulation 4(b) 12(1)(a) 18(a) 12(1)(a) 13(4)(c) 13(6) 13(7) Requirement The Registered Manager must ensure that the home is suitably staffed at all times. The home must ensure that bedsides are only used in exceptional circumstances; where they are in use a thorough risk assessment must be undertaken that is signed and agreed by all relevant parties. The home must take appropriate action to minimise risks to the resident that is ‘prone to wander’. The home must ensure that the resident that may have dementia is appropriately reviewed or reassessed. The home is not registered to provide dementia care. The Registered Manager must notify the Commission for Social Care Inspection of any residents that have been diagnosed as having dementia. The complaints procedure must be updated to reflect the fact that the National Care Standards Commission has been replaced DS0000047113.V301867.R01.S.doc Timescale for action 10/07/06 10/07/06 OP8 3 OP8 12(1)(a) 14(a)(c) 12 (1) 14 (1) 14(2) 12(1) 4(3b) 10/07/06 4 OP8 10/07/06 5 OP8 10/07/06 6 OP16 16(7) 14/08/06 Jeian Version 5.2 Page 24 7 OP18 13(6) 8 OP19 23(2)(O) 9 OP28 4(C) Sch 1 10 OP37 OP38 12(1)(a) 12(1)(b) 17(2) 17(3)(b) by the Commission for Social Care Inspection. The Registered Manager must ensure that staff have access to, and are familiar with, the local authority procedures for the Protection of Vulnerable Adults. This is a repeat requirement from 10/01/06. The Registered Manager must ensure that the external grounds are appropriately maintained and potential hazards are minimised or eliminated. The Registered Manager must ensure information concerning staff qualifications/NVQ’s is not misleading and reflects actual qualifications held. The Registered Manager must ensure that records required to be available for inspection are accessible at all times. 14/08/06 14/08/06 14/08/06 20/07/06 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 OP4 OP27 Good Practice Recommendations The registered manager should ensure that residents are fully consulted in the recruitment process and that their linguistic needs are appropriately addressed within the staffing complement. The registered manager should consider employing an activities co-ordinator to promote choice and offer a wider range of leisure opportunities. The home should ensure that residents and their relatives/representatives are consulted about the range of food available and develop the menu to include fresh food including milk, meat, fruit and vegetables. 2 3 OP12OP14 OP15 Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Jeian DS0000047113.V301867.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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