CARE HOMES FOR OLDER PEOPLE
King Charles Court Marlborough Road Falmouth Cornwall TR11 3LR Lead Inspector
Paul Freeman Key Unannounced Inspection 25th June 2007 10:00 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 King Charles Court DS0000009186.V340426.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. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service King Charles Court Address Marlborough Road Falmouth Cornwall TR11 3LR 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) 01326 311155 01326 319548 kcc@comfortcaregroup,co,uk King Charles Court Limited Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability (30), Terminally ill (30) of places King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users to include up to 30 adults of old age (OP) Service users to include up to 30 adults under pensionable age with a physical disability (PD) Service users to include up to 30 adults with a terminal illness (TI) Total number of service users not to exceed a maximum of 30 Date of last inspection 13th February 2007 Brief Description of the Service: King Charles Court is a Care Home located in Falmouth. It is situated above the town, although close to the amenities. Many of the rooms have views over the Carrick Road and Falmouth Docks. The home is registered for up to 30 residents who require personal and/or nursing care. Accommodation is provided on two floors with a lift to access the first floor. A number of bedrooms have en-suite facilities and all the bedrooms have call bells. There is a large dining room, with a lounge area at one end, on the ground floor; this is next to the kitchen. There is a smaller lounge on the first floor. There is also a small kitchenette on the first floor where staff can make drinks and serve snacks for residents. There is a very small garden in the grounds at the back of the home; this is not accessible to residents. The car parking space to the front of the building is limited. There is a qualified nurse on duty at all times and community nurses visit regularly. There are no barriers to residents receiving visitors and the visiting arrangements are flexible. The fees at the home start from £450.00 and the exact level for each resident is determined by the type of accommodation and the individual care and support needs. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors visited on 26 June 2007 and 3 July 2007 to undertake an unannounced key inspection. The purpose of this inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 13 February 2007 and to inspect other core standards. Therefore some of the key standards considered included care planning, health, staffing arrangements and safe working practices. The registered providers, residents, visitors, manager and staff were also consulted. Records and documents were also considered. Following the last inspection the providers have thoroughly reviewed the operational arrangements in place given the concern s identified and the areas of non-compliance with the regulations. Consequently a range of measures has been put in place to improve and develop the facilities and services provided. The measures are also designed to facilitate regulatory compliance. What the service does well:
All prospective residents needs are assessed before they are admitted to the care home. Each resident has a care plan that summarises their needs and provides staff with some direction about the care and support required. Satisfactory arrangements are in place to meet residents’ health needs and medical services are accessed when required. Residents are provided with a varied and nutritional menu that meets their needs preferences and choices. Residents and visitors describe the food as “good”. Flexible visiting arrangements are also in place and residents said the staff positively welcomed visitors. Good arrangements are in place to protect residents from abuse and any allegations or concerns are reported to the statutory authorities for investigation. There are no apparent barriers to residents or interested parties raising any issues or concerns. Generally the environment is homely and the providers have established a redecoration and replacement plan. Many of the residents’ rooms have been personalised by the occupants and a wide range of disability equipment is provided to assist residents. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 6 Resident and visitors were positive about staff who they described as “kind” and “lovely”. Positive arrangements are in place to make sure that staff is well trained and their skills and knowledge are up to date. Induction arrangements are also in place for new staff. A range of policies and procedures are in place to promote safe working practices. What has improved since the last inspection? What they could do better:
The needs assessments completed before admission continue to require improvement. The providers will then be confident the facilities and services are suitable to meet the person’s needs, preference and choices.
King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 7 The care plans also require significant improvement to make sure staff are provided with clear advice guidance and direction about the care and support required. There are still a number of outstanding issues regarding the administration of medicines. This includes the record keeping arrangements, storage and the time it takes to distribute the medicines. The limited opportunities for residents to participate in stimulating social and recreational activities continues to have a negative impact on their stimulation and does not promote a varied lifestyle. Certain areas of the environment are beginning to look tired and require attention. Residents also commented that repairs are often not undertaken promptly. The providers have recently appointed an addition staff member to address this issue. There continues to be areas where the setting is cluttered. The providers are striving to improve the situation in order that hazards can be minimised. The bathrooms are however frequently cluttered and residents’ toiletries and personal items are often left in the bathrooms and therefore are not being appropriately managed. Although the home is cleaned each day there are areas that require additional attention. This will make sure that good infection control arrangements are in place. The providers need to make sure that minimum numbers of staff are on duty at all times and that reliable arrangements are in place to cover any unexpected staff absences. A registered manager must be appointed to operationally manage the services and facilities. The quality assurance measures also require improvement and good and reliable arrangements need to be put in place. This will assist the providers to make sure the care home is run in the best interests of residents. The risk assessment, risk management and the infection control measures arrangements require improvement in order that resident’s health, safety and well being are safeguarded. 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
King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 9 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 King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 3 and 6. Quality in this outcome area is Adequate. More detailed assessments need to be completed to make sure the providers have a comprehensive picture of prospective residents needs, preferences and choices. The providers will also be more confident the services and facilities are suitable to meet the assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each prospective resident is assessed to make sure that the services and facilities are appropriate to meet the needs of the individual concerned. The prospective resident and there relatives or representatives are also invited to participate in the assessment. In addition the views of any professionals involved are taken into account.
King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 11 The assessments summarise the prospective residents needs but do not always comprehensively address all of their needs, preferences and choices. Therefore more detailed assessments continue to be required in order that the providers are confidant the appropriate care and support required is provided. Residents that had recently moved to the care home said they had been welcomed by the staff and supported to settle in their new environment. The providers do not offer dedicated intermediate care or rehabilitation services but are committed to supporting residents to be as independent as possible. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is poor. The care planning and review arrangements require improvement to make sure that residents receive the care and support they require. Resident’s health needs are generally met. The arrangements to administer medicines have improved but further action is required to make sure robust procedures are in place and residents are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a care plan that broadly outlines their needs and in some instances provides appropriate information, guidance and direction for staff. The care plans are typed but do not specify the date they were put into place. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 13 The quality of the contents of care plans is variable and in a number of instances there was inadequate information to appropriately guide, direct and inform the staff about the care and support required. The providers recognise the current shortfalls and are actively introducing new care planning arrangements to address the current deficiencies. The review arrangements continue to be inconsistent and reviews do not always regularly take place. The record about the reviews are also limited and do not always clearly indicate if any changes are required. The revised care planning arrangements include improved arrangements to review and monitor residents needs. Residents are supported and encouraged to direct their own care as far as possible. A number or residents were unclear about the contents of their care plans and could not recall being regularly consulted. Some of the residents and visitors appeared to be sceptical that changes or amendments could be easily made. However it is evident the new management arrangements and the providers are committed to improving and developing the services and facilities provided. Residents also stated staff generally treated them with respect and were positive and flexible in the care and support provided. The residents stated the staff were better organised and this had positively impacted on the service they receive. There were examples when the inspectors witnessed very positive, caring and respectful interactions between residents and staff. Residents were satisfied with the manner in which their health needs are met and generally expressed confidence in the staff. It is clear that medical services are accessed when required and specialist health professionals visit the care home when needed. Medicines are appropriately stored and residents are able to administer their own medication when it is safe to do so. The qualified nurses assist residents with prescribed medicines where required and a policy and procedure has been established to guide, direct and inform the staff. Following the last inspection the policy and procedures have been comprehensively reviewed and improved by the providers. Therefore better arrangements should be in place to guide the staffs’ practise and promote resident’s health and well being. The administration records were found to be up to date but the Inspectors noted the records continued to be completed before the medicine was administered. This is not an acceptable practice. Furthermore any hand written
King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 14 instruction or directions from a qualified health practitioner need to be signed by two staff. This is not always the case and therefore residents are not fully safeguarded. It is also advised that records regarding temazepan are held in the Control Drug Log to further safeguard residents. The arrangements to administer medication still require review given it took some time for the “round” to be completed. The round finished about an hour and a half before the next round was due. The disposal arrangements have been improved but the temperature of the dedicated secure fridge that holds medicines is not regularly monitored. Generally residents were satisfied about the care and support they receive and a number of residents were complimentary about standards of care and support provided. Some of the residents however indicated there were some inconsistencies in the standard of care they experienced. The providers are aware of the short falls and are in process of taking positive measures to address the situation. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is Poor. The opportunities for residents to participate in social and recreational activities are very limited. This results in a lack of stimulation and restricts the residents’ opportunities to experience a varied lifestyle. The providers have put plans in place to address the shortfalls. A varied and nutritional menu is in place that meets residents’ preferences and choices and promotes their health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection the residents said there was very limited social and recreational opportunities available. The resident’s care plans and assessments are also not very strong about identifying social, leisure and
King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 16 recreational interests and needs and this further inhibits residents’ opportunities. The providers had begun to address the shortfalls and have appointed an Activities Coordinators who was about to commence their duties. In addition the improved assessment and care planning arrangements should positively help to address the current shortfalls. There are no restrictions to residents accessing the community when this is safe. However a high percentage are frail and vulnerable and do not have the opportunity to access the community. This highlights the importance of a varied and stimulating lifestyle within the home. Residents said they had opportunities to decide their own patterns of daily living and generally staff were responsive and supportive towards the choices they made. Therefore some of the residents prefer to organise and manage their own social time. The visiting arrangements are flexible and residents and visitors said the staff were always welcoming. Residents are provided with a varied and nutritional diet and residents said the food was “good”. Visitors also said the “staff are very kind and the food is very good”. Residents have a choice of the meals they have. The kitchen is well organised and good standards of cleanliness are maintained. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 16 and 18. Quality in this outcome area is good. Suitable arrangements are in place to protect residents for abuse and to formally deal with any complaints. This provides residents with further safeguards. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the last inspection the providers have received one complaint and reviewed the policies and procedures in place. The evidence indicates better arrangements are in place and any complaints, issues or concerns are dealt with in line with the regulatory requirements. Therefore there do not appear to be any barriers preventing residents from raising issues or concerns. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 18 The home has a satisfactory adult protection policy. In house training takes place and some of the staff has attended Department of Adult Social Care adult protection training. A suitable whistle blowing policy and procedure is also in place. This enables the staff to report any concerns or issues to a third party if they feel unable to raise the matter with the providers. This also further safeguards residents. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 19 and 26. Quality in this outcome area is adequate. The facilities are homely and arrangements have improved to maintain the environment to the required standard. Certain areas do require attention so that good facilities are provided throughout for residents. Storage continues to be a concern and improvements are required regarding cleanliness. Better arrangements need to be established to manage and look after residents’ toiletries and other personal items. This judgement has been made using available evidence including a visit to this service. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 20 EVIDENCE: Residents live in a well-maintained environment, which is relatively homely and comfortable. The providers have an ongoing maintenance programme and a re-decoration and refubishment programme is in place. There are however areas of the home that look tired or where and furniture needs replacing. Equally there were some outstanding minor repairs that had not been undertaken. The providers have recently appointed additional maintainance staff and were confidant the issues would be quickly resolved. Personal laundry is dealt with in house, the sheets and towels are contracted out. There are suitable hand-washing facilities for staff and alcohol hand cleansing gel is used. Protective clothing is also provided. Residents were generally satisfied with the facilities provided and many have personalised their bedrooms. A key issue at the home is storage and the providers have begun to address this issue. The environment was found to be less cluttered but there is evidently limited storage space. This results in equipment and other supplies continuing to be inappropriately stored. This therefore continues to be a potential hazard for residents, staff or visitors. There is a range of communal disability aids and equipment provided to assist residents. Where appropriate individual residents have their own equipment following a specialist assessment. The providers had taken steps to make sure sufficient numbers of appropriate mobile hoists are in place. This has addressed the shortfall identified at the last inspection. The providers had also made sure that where cot sides are required a risk assessment is in place and appropriate protectors are provided in order to safeguard the residents. The sluice room on the first floor had been repaired but the ground floor sluice was not in operation. This requires urgent attention to make sure that robust infection control measures are in place. The providers are aware of the situation and have taken intermediate action to minimise any negative impact. The housekeeping staff maintains a decent standard of cleanliness throughout the care home but there are areas that evidently require “deep” cleaning on a more regular basis. The providers are aware of the shortfalls and are taking steps to address the deficiencies. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 21 There are a number of communal bathrooms and toilets around the care home in addition to the en-suite facilities available. The providers are currently in the process of refurbishing and improving two of the bathrooms. The current facilities and arrangements require review given it was difficult to access certain toilets given the other items stored in them. In addition the Inspectors found a number of residents items in the bathrooms that included toothbrushes, deodorants, glasses and hearing aids! This is not an acceptable situation. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is adequate. The staffing arrangements have been improved to make sure sufficient staff are on duty to meet the needs of residents. The availability of care has improved but the providers need to make sure the staff have the required competencies to meet the individual needs of residents. The recruitment arrangements have improved and safeguard residents. Good training and induction arrangements are in place for all staff. Therefore staff is provided with up to date knowledge and information so that good standards of care can be maintained. The record keeping arrangements regarding induction would benefit from improvement. This will make sure that staff has appropriately undertaken and completed the programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 23 The staff team comprises of qualified nurses, care staff and housekeeping and kitchen staff. A qualified nurse is therefore on duty at all times and oversees the work of the care staff as well as and meeting residents’ health needs. The providers have continued to review and develop the staffing arrangements and a number of staff have been recruited following the last inspection. This has been to replace vacant posts as well as to increase the staffing compliment. Generally the residents said they were satisfied with the staffing arrangements but commented that unplanned staff absences were on occasions not filled. The residents considered this did have an adverse effect on the service they experienced. The providers need to give further attention and consideration to this area. Residents said the majority of carers were reliable and provided a good standard of care. Residents described the majority of staff as “kind” and “lovely”. Some residents commented that a minority of staff tended to rush their duties and responsibilities and considered this had an adverse effect on the standard of care they received. They also commented this negatively impacted upon their ability to direct their own care and be in control of events. The staff considered they worked well as a team and stated they are mutually supportive to each other. The staff also said they were clear about their roles and responsibilities. The staff were also positive about the training opportunities provided and were confidant their training needs were well met. This makes sure that staff have up to date skills and knowledge to meet residents needs safely. The recruitment vetting and selection arrangements have improved following the last inspection. The providers however need to be mindful that records are kept at the care home to evidence a POVA check had been completed before employment commenceds. Although the providers stated this was always the case some of the records were not available for inspection given they were at the companies central office. The other recruitment records required by regulation were in good order. The providers have also established an induction programme for all new staff that commences on the first day of employment. It was not possible to audit the progress for new staff given the staff holds the records. There also appeared to be no arrangements in place for the providers to monitor progress other than the staff providing their records. The staff also commented their induction records were not provided from the first day of employment. The staff that had recently participated in induction positively viewed the experience and information provided. However the providers need to make
King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 24 sure the current programme reflects the induction standards set by Skills for Care. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 25 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 31, 33, 35 and 38. Quality in this outcome area is adequate. The registered manager position is vacant but a suitable interim manager is in post to operationally manage the services and facilities. The registered providers also maintain regular contact and visit the care home at least once a week. Health and safety measures need to be improved to make sure that resident’s health; safety and well being are not compromised. This judgement has been made using available evidence including a visit to this service. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager is no longer in post and the providers have appointed a interim manager who has also made an application to be the registered manager. At the time of the inspection the application had not been determined. The providers have also reviewed the management arrangements. This had resulted in the recruitment t of a new deputy manager. The providers consider the new management team will able to address the outstanding requirement and improve the facilities and services offered to residents. The staff were positive about the new management arrangements and said that advice, guidance and support was available when required. The new manager is therefore working closely with the residents to make sure they are receiving the care and support required and to identify areas that require improvement. The providers have also begun to regularly undertake regulation 26 visits which provide a snapshot of the services and facilities provided. The providers have also begun to make sure that a monthly report of the findings of the visits is provided to the manager and the commission. The providers said the quality assurance measures continued to be reliant on informal consultations with residents, staff and visitors. The providers are in the process of establishing more formalised arrangements in order that services and facilities can be robustly assessed. The financial arrangements and records at the home appear to be in good order. A range of measures to promote safe working practices is in place. Certain measures were successfully making sure that good standards were attained that safeguarded residents. These include servicing and maintenance of equipment and COSH guidance and information. In addition the providers have continued to improve and develop the fire safety and fire precaution arrangements and regular staff training regarding fire takes place. However the risk assessment and risk management arrangements still require further improvement. This is because risk assessments are not always completed when a situation arises that could compromise the health, safety and well being of the residents. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 27 The providers have put plans in place that will address certain elements of the current shortfalls. This can be illustrated by the planned improvements to the assessment and care planning arrangements. Other areas that require attention include waste disposal and infection control measures. It is recommended that a comprehensive environmental risk assessment is undertaken to make sure that good arrangements are in place throughout. King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 29 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 OP3 Regulation Requirement Timescale for action 30/10/07 14(1)(a-c) Detailed assessment must be completed on each prospective resident to make sure the providers have a comprehensive picture of the service users needs, preferences and choices. 15(1) Each resident must have a care plan that details their needs and provides staff with the information, guidance and direction to provide the care and support required. 2. OP7 30/11/07 3. OP7 15(2)(b-c) Each care plan must be regularly reviewed and developed when necessary so that service users needs are met at all times. This is re-notified from 02/05/07 13(2) The Registered Provider must make sure that medicines are stored and administered safely. Accurate and comprehensive records must be in place regarding the administration of medicines and homely remedies.
DS0000009186.V340426.R01.S.doc 30/11/07 4. OP9 30/08/07 5. OP9 13(2) 30/08/07 King Charles Court Version 5.2 Page 30 6. OP12 16(2)(mn) 13(4)(a-c) A range of stimulating recreational and social opportunities must be provided. Satisfactory arrangements must be established to store and keep equipment in a manner that safeguards service users. The bathrooms must be reasonably free of hazards and potential risks must be eliminated. The sluice facilities on the ground floor or suitable alternative arrangements to minimise the spread of infection must be in place. There must be sufficient staff on duty at all times to meet the assessed needs of the residents whilst taking into consideration the size and layout of the home, dependency of service users and the number of residents accommodated. A registered manager must be appointed to manage the care home. Reliable and measurable quality assurance arrangements must be established to evaluate the service and facilities provided. 30/12/07 7. OP19 30/12/07 8. OP21 13 (4)(ac) 30/08/07 9. OP26 13(3) (4)(a-c) 30/09/07 10. OP27 18 (1)(a) 30/09/07 11. OP31 8(1) 30/10/07 12. OP33 24(1) 30/12/07 King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 31 13. OP38 13(4)(a-c) Robust and reliable risk assessments and risk management arrangements must be in place where any situation arises that could potentially compromise a services users health, safety or well being. This is re-notified from 30/04/07 30/10/07 King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 32 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 OP7 Good Practice Recommendations The resident or representative should sign and date the needs assessment and care plan. Where it is not possible to obtain a signature the individuals participating in the assessment a reason should be recorded. The registered providers should keep a copy of all the recruitment records required by regulation at the care home. The induction records should be put in place from first day of employment. A satisfaction survey of residents and their relatives should be undertaken. 2. 3. 4. OP29 OP30 OP33 King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI King Charles Court DS0000009186.V340426.R01.S.doc Version 5.2 Page 34 - 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!
