CARE HOMES FOR OLDER PEOPLE
Kingfisher House Residential and Nursing Home St Fabians Close Newmarket Suffolk CB8 0EJ Lead Inspector
Jane Offord Key Unannounced Inspection 23rd May 2006 09:40 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 DS0000024427.V296355.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. DS0000024427.V296355.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Kingfisher House Residential and Nursing Home Address St Fabians Close Newmarket Suffolk CB8 0EJ 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) 01638 669919 01638 669929 kingfisher.house@fshc.co.uk www.fshc.co.uk Four Seasons Health Care Ltd Post Vacant Care Home 91 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (33), Old age, not falling within any other of places category (62) DS0000024427.V296355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Kingfisher House, Newmarket, is part of Four Seasons Health Care. The house is purpose built to provide nursing and residential care for a maximum of 62 older people. Kingfisher House has two floors with a shaft lift accessing the first floor. The home has a lounge on each floor, a smoking room and a laundry room situated on the ground floor. Both floors have separate dining rooms, which are available for service users to eat their meals. There are 58 single bedrooms and four shared rooms each having the advantage of an en suite toilet and wash basin, shared bathrooms are situated on each floor. A new unit (Spillers) was opened in September 2005 and provides an additional 29 places for people who have dementia. The layout is similar to Kingfisher House in that there are bedrooms and communal areas on both floors. There is a vertical passenger lift for use between the two floors. Admissions have been made to both floors now although the facility is not yet full. Meals are transported from the main kitchen. There is a separate staff team consisting of senior carers and care assistants. The fees range between £397.96 and £632.30 per week depending on whether a resident has residential needs or nursing needs and the level of dependency within that. DS0000024427.V296355.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key inspection focussing on the core standards for older people. It was carried out by two inspectors accompanied by a pharmacy inspector who will generate a separate report that should be read in conjunction with this report. The inspection took place on a weekday between 9.40 and 17.30. The pharmacy inspector was there between 9.40 and 13.30. For the evidence in this report the two inspectors looked at a number of residents’ files and care plans, some staff recruitment files, the duty rotas, menus, accident/incident records and a number of maintenance records. Discussions were had with residents, visitors and staff. A tour of all parts of the home was made. On the day of inspection an acting manager from another home in the Four Seasons’ group was in charge. It was their first day in the home and they were orientating themselves. CSCI had been notified earlier in the month of an outbreak of a diarrhoea and vomiting germ (D V) affecting some residents and some staff. In a follow up to the continuing D V concerns an Environmental Health Officer (EHO) had visited the home on four occasions the previous week. The acting manager was addressing the requirements left by EHO in relation to the kitchen. The residents seen and spoken with were generally happy with the care they received and said staff were kind and willing. Residents were appropriately dressed and looked comfortable whether in their rooms or one of the communal rooms. What the service does well: What has improved since the last inspection?
There was evidence that work has been done to encourage staff to review and evaluate care plans and the interventions in place. The care plans seen had been reviewed monthly. DS0000024427.V296355.R01.S.doc Version 5.2 Page 6 What they could do better: 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. DS0000024427.V296355.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 DS0000024427.V296355.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): 3, 5, 6. People who use this service can expect to have their needs assessed, although not always in depth, and have an opportunity to visit prior to moving into the home. The service does not offer Intermediate Care. EVIDENCE: There was evidence in the residents’ files seen that a pre-admission assessment by a senior member of staff is undertaken. The areas covered were past medical history, medication, oral health, sensory needs, diet and activities of daily living. Other headings were religious and cultural needs, cognitive assessment, social history, sexuality and recreational needs. These latter headings were in most cases not addressed or contained very limited information. One file seen had an assessment done and a note that the person should have their name placed on the waiting list for admission. Another file had recorded the date the first enquiry was made about admission.
DS0000024427.V296355.R01.S.doc Version 5.2 Page 9 One resident spoken with said they recalled the manager visiting them at home before they came into Kingfisher. Relatives said they had visited the home and been shown the room their relative would have if they agreed to move in. It was a double room but they were promised a single room when one became available. Their relative was given a single room shortly after their admission. Some visitors were observed in the reception and the administrator had given them some of the home’s information and agreed to post further details to them. DS0000024427.V296355.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, 10. People who use this service can expect to have a plan of care but cannot be assured it will cover all their assessed needs nor can they be assured that their privacy and dignity will always be respected. Standard 9 will be the subject of a separate report that should be read in conjunction with this report. EVIDENCE: An enforcement notice relating to medication administration and procedures had been issued to the home in March 2006 and in a follow up visit some improvement had been noted. Some staff had been disciplined and regular audits of medication practice had been conducted, however there remained concerns and four requirements were left at the follow up visit. The pharmacy inspector was to inspect medication practice and procedures during this visit and a separate report would be generated. A total of seven residents’ files and care plans were seen, five in Kingfisher and two in Spillers. The admission assessment records had headings for past medical history, oral health, sensory needs, diet, activities of daily living, religious and cultural needs and a cognitive assessment. The information
DS0000024427.V296355.R01.S.doc Version 5.2 Page 11 recorded in the files seen was limited. Many sections had no information at all. Some areas identified in the assessment were not then carried through to a care plan. One resident had problems of angina, difficulty breathing and falls. The care plan had interventions for self-medication, warfarin treatment, a skin tear and vomiting. Another resident had needs identified as self neglect, poor hygiene/diet and osteoporosis. The care plan interventions were for hygiene, confusion and difficulty sleeping in a bed due to osteoporosis. There was no reference to any potential risk incurred by sleeping in a chair. Some residents’ care plans were fuller and included interventions for mobility, continence, weight loss, history of falls, night needs and monitoring of blood pressure. There was evidence that work had been done to ensure that care plans and assessments were evaluated and reviewed on a monthly basis. However the assessments, for example nutritional assessment and Waterlow (for tissue viability) did not prompt the development of care plan interventions even when the scores were in the ‘high risk’ or ‘very high risk’ level. Other assessments such as cognitive or social were either blank or only partially completed. Areas that were frequently blank were personal preferences, sexuality, hobbies and interests and baseline observations on admission. Many areas were not signed or dated. One resident in Spillers wing had been transferred from Kingfisher house but, although the transfer was because the residents’ needs could no longer be met in Kingfisher, there was no evidence of any assessment and confirmation that Spillers could meet the identified needs. The files recorded the contact details of health professionals involved with the resident such as GP, community nurse and hospital out patient appointments. Records of visits by health professionals were recorded and the instructions left noted. Residents and visitors spoken with felt the care being given was acceptable. One resident who had been unwell over the previous few days said, ‘the nurses do their level best to cope. Many are extremely good but very busy’. One inspector observed a member of staff leaving a resident’s room to go into an adjoining resident’s room to fetch a continence pad and return to the first room. The resident had been left with another carer but was naked and in a hoist sling in full view of anyone passing in the corridor. Most interactions between staff and residents were friendly and appropriate but there were some observed incidents where the carers did not respect the needs of the resident. One resident was being taken to the lounge and wanted to ask the carer a question. The carer talked over them and told them they needed to come to the lounge for their tea. In another incident a resident rang the buzzer and a carer shouted at them, ‘XXXX that’s the alarm, come and have a cup of tea’. DS0000024427.V296355.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. People who use this service can expect to be encouraged to maintain contact with family and friends and exercise control over their lives but they cannot be assured that they will be offered meaningful activities or a wholesome diet. EVIDENCE: The home does not have an activities co-ordinator at present. Some residents and visitors spoken with said there had been someone in post who left and they notice the difference in the lack of activities arranged now. There was no activities programme available to see. One resident’s file in Spillers recorded some activities such as played ‘Scrabble/Connect 4, had nails manicured’ and ‘made poster for Easter bonnet competition’. Throughout the day there were a number of visitors coming and going. Several residents had visits from very young grandchildren and great grandchildren. Visitors spoken with said there was usually no restrictions on visiting but the home had telephoned them the previous week to let them know that during the D V episode the home was closed to visitors. They said the home kept them well informed about their relative. Evidence was seen of personal possessions being brought into the home with the residents. Some rooms were full of personal items and photographs. The residents’ files also showed that some residents self medicate.
DS0000024427.V296355.R01.S.doc Version 5.2 Page 13 Copies of the menus were requested but were not available as the cooks decide from day to day what they will prepare. On the day of inspection the main lunch was to be sausages with mashed potato and vegetables. One resident got themself to the dining table at least twenty minutes before the meal was due to be served. They said they were hungry and they loved sausages. Later in the day the company chef produced some menus that they proposed to follow in the next weeks. These showed a four week rotation with a choice of two main dishes at lunch, a choice of soup, sandwiches and a savoury at supper and an alternative menu available at all meals that included fish fingers, poached eggs, omelettes, beans on toast and jacket potatoes with fillings. The visits from EHO referred to earlier in this report left a list of requirements as a result of their findings. Some of these findings included cross contamination of food, poor stock rotation, inadequate temperature controls and unfit food found on the premises. In view of the ongoing situation with EHO an in-depth inspection of the food storage and kitchens was not undertaken at this inspection. DS0000024427.V296355.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. People who use this service can expect to have complaints taken seriously but cannot be assured they will be protected from abuse. EVIDENCE: On the day of inspection the acting manager was unable to find the complaints log. CSCI have been aware of an ongoing POVA investigation that was reported in March. CSCI are not aware of any other complaints. Previous inspections have found that the complaints policy is robust and complaints are investigated seriously. Residents and visitors were able to say who they would complain to if there was a problem. The home has the up to date guidelines from the Vulnerable Adult Protection Committee in Suffolk. Training records seen showed that POVA training had not been done recently. Although staff spoken with were clear that they would report anything that they thought was potentially abusive they confirmed that they had not received POVA training. In view of previous evidence from a POVA investigation that was related to pressure sores developing, it is of concern that, at this inspection, there continues to be little care plan provision for addressing the needs of any resident identified at risk. The care plans seen had no preventative interventions or any special equipment such as low loss air mattresses recorded. DS0000024427.V296355.R01.S.doc Version 5.2 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, 22, 24, 25, 26. People who use this service cannot be assured that they will live in a safe, hygienic or clean environment or that they will have all the furnishings they need. EVIDENCE: The home employs three domestics who are responsible for the cleanliness of the whole of the two buildings, Kingfisher and Spillers. They cover seven days a week but one works eight hours, five days a week and the other two work six hours, five days a week. At the week end there is one domestic to cover both buildings. All the domestics were spoken with on the day of inspection and clearly they are not able to manage the workload to their satisfaction. They all said they need more domestic staff to do the work to a satisfactory level. During the day a tour of the environment revealed baths and basins with mildew and lime scale, dirty cups and plates left in one of the dayrooms, breakfast trays left in a staff room, with left over food, cigarette butts in one of the residents’ lounges (there is a no smoking policy in place), marmalade on the dining room wall downstairs and crumbs and cereal on the dining room
DS0000024427.V296355.R01.S.doc Version 5.2 Page 16 carpet from breakfast that were not cleared up by lunchtime. The bins in all the toilets and bathrooms were full all day and still not emptied by late afternoon. Upstairs in Kingfisher there was a persistent smell of urine in one corridor and one resident’s room smelt strongly of vomit. Some rooms seen had no chair for a visitor to use and one room had no chairs at all. Some bedside lamps had no bulbs in them. In one case the bed had bed rails attached so if the resident was in bed they would have been unable to access the main light but had no bedside light bulb either. Emergency call cords were tied up out of reach in a number of bathrooms and the call box in Spillers upstairs lounge had been removed from the wall leaving bare wires exposed. Records of water temperatures were seen and most were within safe limits. One tap in Kingfisher was recorded as having a temperature of 50 degrees centigrade. Some taps were randomly tested and found to be within safe limits except the taps in the kitchenettes in Spillers. These taps were registering 60 degrees centigrade. The maintenance person said there were no pre-set valves on those taps. The laundry was visited and the laundry worker explained the system for keeping residents’ clothing in order so it is returned to the correct resident. Residents spoken with said the personal laundry service was good. Soiled and infected linen arrives at the laundry in alginate bags to go directly into a washing machine on a sluicing programme. Some bags were noted to have not been sealed prior to transporting them. The laundry does not have a hand-washing basin for staff use. DS0000024427.V296355.R01.S.doc Version 5.2 Page 17 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. People who use this service cannot be assured that staff have all the correct checks done at recruitment or that they have sufficient training for the work. EVIDENCE: Three new staff files were seen and all contained evidence of an enhanced criminal records bureau (CRB) check and photocopies of documents to confirm identification. One file had no references and none of them had a recent photograph of the member of staff. They all had evidence that the staff had attended a recognised induction day. Training records and discussions with staff show that recently updating training has not been taking place. One member of staff in Spillers has not received any moving and handling training and no staff spoken with have had any POVA training. The staff in Spillers have had one session of dementia care. In response to the D V outbreak all staff have had a training update on infection control and the precautions that should be taken to prevent cross infection. The rotas were seen and showed that there was a trained nurse on each floor of Kingfisher for every shift supported by carers. Spillers had a senior carer each shift with four other carers on an early and three on a late shift. The manager was supernumerary and in addition there was an administrator and receptionist, a maintenance person and a maintenance assistant. The number of care staff in the home excluding trained nurses is 52. Fourteen have achieved NVQ level 2 and two have NVQ level 3.
DS0000024427.V296355.R01.S.doc Version 5.2 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38. People who use this service can expect that their financial interests are safeguarded but they cannot be assured that staff are supervised or that their health and safety is promoted. EVIDENCE: In the last year there has not been a registered manager in place for the service. The post has been filled temporarily by acting managers from other homes in the Four Seasons group. The manager has now been appointed but has not made an application to CSCI yet and at present is on sick leave. At the follow up inspection after the enforcement notice was issued they were taking some steps to address issues and concerns raised at previous inspections. The staff files seen had no evidence of supervision sessions taking place. Staff spoken with confirmed that they did not receive supervision.
DS0000024427.V296355.R01.S.doc Version 5.2 Page 19 The administrator explained the system in place for managing the residents’ personal money. The money is all kept in a central account but individual transactions and balances are available and statements are given to the residents or kept in their financial files. As the account does not accrue interest the amounts saved are limited. The administrator said one resident has a substantial amount in their account and no family to manage their affairs for them. Four Seasons management has agreed to open an investment account in the name of the resident so their money will work for them. Residents and visitors spoken with were clear that they could speak to any member of staff about the care and running of the home. However there is not a formal system of obtaining the views of residents or their families about the service offered at the home. Residents’ files and care plans are stored at the nurses’ stations on open shelves that are accessible to anyone passing. The nurses’ stations are not always manned. In one corridor upstairs in Kingfisher there was a filing cabinet that appeared abandoned. On inspection it was unlocked and contained archived files belonging to residents together with MAR sheets and progress notes. In discussion with the kitchen staff it was found that none of them had up to date food hygiene training. Care staff spoken with who help distribute meals had also no food handling training. All staff spoken with talked about the training the previous day on infection control which was held in response to the D V outbreak that the home was having. One domestic was observed working without protective gloves and apron. When questioned they agreed they should be wearing them but had not bothered on that day in spite of attending the previous day’s training. The domestics’ trolleys, with the cleaning agents, were seen on several occasions in public places and unattended. Staff said that the home had no vomit bowls and that during the present D V outbreak they had to use plastic washing bowls if a resident was sick. The overlay foam mattresses had no plastic covers to protect them and staff were improvising with incontinent sheets but with the D V problems had had to throw out a mattress that morning as it had been soiled. Staff said that at times the commode pots came out of the washer still dirty. The maintenance person said the washers had been in the home since it opened, at least ten years and they had never been serviced. On inspection the washers were marked with lime scale and, in places rusted. The home has a problem with water pressure and the washers work by flushing the pots and then steaming them to sterilise them. Poor water pressure could affect the efficiency of the process. DS0000024427.V296355.R01.S.doc Version 5.2 Page 20 The poor water pressure also affects the delivery of water to some of the residents’ rooms particularly on the top floor of Kingfisher. One resident said the water to their basin had not been hot that day and staff had fetched hot water in a plastic bowl for them to wash that morning. The maintenance person said that Anglia Water has been contacted about the water pressure problem and they were due to visit soon to see if they could rectify it. Some fire doors were seen to be wedged open and the door to the small kitchen in Charnwood unit was propped open with a bin. In some bathrooms there were residents’ personal toiletries, some named and some not. DS0000024427.V296355.R01.S.doc Version 5.2 Page 21 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X 2 X 2 1 1 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 1 1 DS0000024427.V296355.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP3 OP7 Regulation 14 (1) 15 (1) Requirement A full assessment of prospective residents’ needs must be undertaken prior to admission. A resident’s care plan must include interventions for all assessed needs. This is a repeat requirement. When a resident has a Waterlow or nutrition score that puts them in a risk category an appropriate care plan must be generated. This is a repeat requirement. Staff must work with residents in a way that respects their privacy and dignity. A programme of meaningful activities must be developed in consultation with residents. The requirements made by EHO in respect of the kitchens and food storage and preparation must be complied with. All staff must receive POVA training. This is a repeat requirement. All call bells must be maintained in working order and emergency cords must not be tied up out of reach.
DS0000024427.V296355.R01.S.doc Timescale for action 23/05/06 23/05/06 3. OP7 13 (4) (c) 23/05/06 4. 5. 6. OP10 OP12 OP15 12 (4) (a) 16 (2) (n) 16 (2) (i) (j) 13 (6) 13 (4) (c) 23/05/06 17/07/06 12/06/06 7. 8. OP18 OP22 31/07/06 23/05/06 Version 5.2 Page 23 9. 10. 11. OP22 OP24 OP25 13 (4) (c) 16 (2) (c) 13 (4) (a) (c) 16 (2) (k) 13 (3) 13 (3) 18 (1) (a) 12. 13. 14 15. OP26 OP26 OP26 OP27 16. OP28 18 (1) (a) (c) 17. OP29 19 (1) 18. OP30 18 (1) (c) 19. 20. 21. OP30 OP31 OP33 18 (1) (c) 8 (1) 12 (3) The bare wires from the call bell box in the upstairs lounge in Spillers must be made good. All residents’ rooms must be furnished with adequate furniture and furnishings. All taps must be fitted with preset valves and water temperatures kept to safe levels close to 43 degrees. Steps must be taken to keep the home free of offensive odours. The infection control policy and management of soiled linen must be enforced. A hand-washing basin must be fitted for use in the laundry. A review of the arrangements and numbers of domestic staff employed in the home must be urgently undertaken. Staff training and the achievement of appropriate qualifications for the work they do must be facilitated so residents are in safe hands. Evidence that all the checks required in Schedule 2 have been undertaken must be retained in staff files. This is a repeat requirement. A programme of staff training and updating in mandatory subjects must be devised and implemented including specific training in dementia care for the staff in Spillers. Kitchen staff must undertake food hygiene training urgently as required by the EHO. The appointed manager must send an application for registration to CSCI. A system to receive formal feedback from residents about the running of the home and their care must be implemented.
DS0000024427.V296355.R01.S.doc 23/05/06 30/06/06 23/05/06 12/06/06 23/05/06 30/06/06 30/06/06 31/10/06 23/05/06 31/07/06 30/06/06 30/06/06 31/08/06 Version 5.2 Page 24 22. OP36 18 (2) 23. 24. 25. 26. OP37 OP38 OP38 OP38 17 (1) (b) 13 (4) (c) 13 (4) (c) 13 (4) (c) 27. OP38 23 (4) (c) (i) 13 (4) (c) 13 (3) 13 (3) 28. 29. 30. OP38 OP38 OP38 A programme for staff supervision must be reinstated as soon as possible. This is a repeat requirement. The residents’ files must be kept securely to preserve confidentiality. All the requirements relating to the kitchens made by EHO must be met. All commode pot washers must be serviced to ensure they are functioning correctly or renewed. The water system must be adjusted so a supply of hot water reaches all residents’ rooms. Fire doors must not be wedged open. Any that are required to be open during the day must be fitted with self-closure devices. Domestic staff must comply with COSHH regulations and not leave their trolleys unattended. Adequate equipment must be provided for the care staff to perform their duties properly. The infection control policy regarding the use of protective clothing must be enforced. 30/06/06 12/06/06 30/06/06 30/06/06 30/06/06 23/05/06 23/05/06 23/05/06 23/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000024427.V296355.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
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