Inspection on 16/02/09 for Knoll House

This inspection was carried out on 16th February 2009.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Knoll House Studham Lane Studham Nr Dunstable Bedfordshire LU6 2QJ Lead Inspector Mrs Louise Trainor Key Unannounced Inspection 16th February 2009 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 Knoll House DS0000072747.V374208.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. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Knoll House Address Studham Lane Studham Nr Dunstable Bedfordshire LU6 2QJ 01582 873607 01582 873607 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) Silver Tree Care Ltd Jane Munford Care Home 22 Category(ies) of Dementia (22), Mental disorder, excluding registration, with number learning disability or dementia (22), Old age, of places not falling within any other category (22), Physical disability (22) Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Physical Disability - Code PD Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is 22 New Service 2. Date of last inspection Brief Description of the Service: Knoll House is situated in a rural location in a village just outside of Dunstable. The proprietor is Silver Tree Care Ltd. Accommodation includes single occupancy bedrooms, two lounges, a communal dining room, bathrooms and toilets throughout the home. There is a large wellmaintained garden and patio area alongside spaces for car parking within the grounds of the home. The fees for this home vary from £456.00 per week, to £580.00 per week, depending on the funding source and assessed needs of the person. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection for this service, since New Providers took over the business in September 2008. The Manager Jane Munford has remained in post throughout this transition period. She was present throughout this inspection, which was carried out on the 16th of February 2009, by Regulatory Inspector Mrs Louise Trainor, between the hours of 10:00 and 16:00 hours. One of the owners was also present for some of the inspection, and was involved in the feedback given both during, and on completion of this inspection. During this inspection we tracked the care of two people who live in this home. This involved reading their records and comparing what was documented, to the care that was being provided. We also looked at the pre admission work that had been done for someone who was due to be admitted on the day of the inspection. Documentation and records relating to: staff recruitment, training and supervision, medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this six-hour inspection. A full tour of the premises also took place. We would like to thank everyone involved for their support and assistance during this visit to the home. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Supervision records were examined, and indicated that staff are receiving some 1:1 sessions with the manager, however this is rather ‘hit and miss’ at the moment. We were also concerned that since the new owners took over the home, the manager is lacking any peer support or formal supervision. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 7 This service has a complaints policy on display and easily accessible to residents, however records of complaints, investigations and responses are not always recorded. The home tries to be flexible and attempts to provide a service that is as individual as possible, however, although some residents are given choices, this process could be improved to include those with more severe disabilities. We did not see any evidence, in the files that we looked at, to suggest that any planning or wishes relating to death or dying are addressed and documented. People receiving care in this home are generally happy with the way staff deliver care and respect their dignity, however due to some gaps in the review process, there may be an inconsistency in the delivery of care. There are some gaps in the recruitment process so that residents and staff may not always be protected. An immediate requirement was issued relating to this matter. This service recognises the importance of training and is in the process of delivering a programme that meets the National Minimum Standards. 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. The summary of this inspection report can be made available in other formats on request. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, and was being completed appropriately. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There is a Service User Guide and a Statement of Purpose in place for this home. These document is held electronically and reviewed at regular intervals, and are on display in the dining room, so they are easily accessible to residents and their relatives at all times. The documents that we saw correctly reflected the details of the new owners, present management of the home and contact details for The Commission for Social Care Inspection (CSCI). Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 10 We viewed a pre admission assessment that had been carried out in preparation for an imminent admission. The document was clearly dated and signed. The manager had carried it out on the 6th of February 2009 in preparation for an admission due to take place on the 16th of February 2009. Generally the document contained sufficient details relating to individuals’ needs, and the manager was using this information to assist in generating an initial care plan for this admission. Contracts of terms and conditions were in place for the residents’ whose files we examined. Some of the information relating to the Commission for Social Care Inspection (CSCI) is in need of review. This home does not provide intermediate care. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9, 10, 11 People who use this service experience adequate quality outcomes in this area. People receiving care in this home are generally happy with the way staff deliver care and respect their dignity, however due to some gaps in the review process, there may be an inconsistency in the delivery of care. Medication records are generally in order, contain the required entries and are signed appropriately by staff. Internal auditing could be improved. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the personal files of two of the residents who live at Knoll House. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 12 Files were tidy and generally well organised. There was a personal profile in each, which gave details of families, holidays, siblings, careers and individual personality traits, such as being shy. There was a clear diagnosis of physical and mental health conditions in these files, and an overview of how each individual presented. However from one of the files we looked at, we understood that this individual was very social and loved to join in activities. This was not currently the case. This had been this persons presentation on admission some years ago, and infact they were now very limited as to what they could participate in due to their deteriorating condition. It is important that this information is kept under review to avoid any confusion in the delivery of care. Both files that we looked at contained various risk assessments, which identified the level of support each person required to minimise risks to them. These risk assessments were reflected in the individual care plans. These documents were all being reviewed on a monthly basis to reflect any changes in need. We did however notice in one of the files we inspected, that the review for one care plan on nutritional needs had been written on the sheet of the care plan for personal hygiene. This could cause confusion. However there were also short-term care plans that were generated as conditions developed that required attention, such as chest infections. Another example in one of the files, identified where the individual had sustained a fractured wrist that was required to be in a plaster cast. The care plan identified how this affected the level of support required. Discussions with residents and visitors to the home indicated that people are generally satisfied with the care provided in this home, and the relatives of one resident confirmed that they do feel involved with their loved ones care. Residents were relaxed, happy, well presented, and said they felt well looked after. Observations of care, identified people being treated with respect, and addressed in a way that was their preference, some by Christian names and others as Mr or Mrs. We examined the Medication Administration Record (MAR) sheets for six of the residents presently living in the home. These were well completed with signatures and omission codes where necessary. As this was the first day of the new MAR sheets we also looked at a small sample of MAR sheets from the previous month. These were also correctly completed. We were able to reconcile most of the stocks appropriately. There were no Controlled Drugs in use in the home at the time of this inspection, however appropriate storage and recording facilities are available if required. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience adequate quality outcomes in this area. The home tries to be flexible and attempts to provide a service that is as individual as possible, however, although some residents are given choices, this process could be improved to include those with more severe disabilities. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we visited the kitchen and observed the midday meal service. The kitchen was clean, tidy and well organised. Fridges and freezers were adequately stocked, although produce that had been opened and then stored in the fridge was not always dated. We looked at the menus, which the chef told us he was in the process of reviewing. Although the menus were varied, there was little evidence to suggest that choices are offered to everyone each mealtime. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 14 We observed the lunchtime service and although residents were being asked. “What flavoured drink would you like?” and if the meal was sufficient for them, everyone was served chicken pie and we did not see anyone being offered an alternative, despite being told that salads etc were always available on request. There was also no evidence of menus on display in a format, such as pictorial, that would assist those residents with dementia to make choices more easily. Since the inspection pictorial menus have been placed on display in the day room, and produced in booklet format. There were activity programmes on display around the home, and an information sheet on the notice board in the dining room, identified the aims and benefits of different activities. However during this visit, with the exception of one resident playing ‘snakes and ladders’, we witness very little in the way of activities, other than residents ‘watching’ the television. There were several visitors in the home at different times during the day, and the concept of residents’ maintaining relationships and involving families in their loved ones daily lives is an integral part of this home’s philosophy. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 15 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): 16, 18 People who use this service experience adequate quality outcomes in this area. This service has a complaints policy on display and easily accessible to residents, however records of complaints, investigations and responses are not always recorded. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is on display and easily accessible to residents and visitors to the home. This document details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We viewed the complaints files, of which there is one for formal complaints and one for minor complaints. Although all complaints made to the home were recorded. There was no evidence to identify how issues had been investigated and resolved. For example there was a complaint logged relating to ‘a rude carer’. There was a bullet point list of what was to be done, however, no information or record of meetings was filed, and there was no formal response letter. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 16 Safeguarding issues were also clearly recorded, and reported appropriately. There had been one referral made since our last visit, which we were already aware of. This had been managed appropriately. Documentation indicates that the manager liaises with the safeguarding team as and when necessary and is aware of her role. The Safeguarding training for some staff is now overdue, as there had been a break in the training systems over the past nine months, during the sale of the home. However this is now being addressed and a training programme is in progress to ensure all staff undergoes this training. We were concerned that there were some workers contracted into the home, such as the plumber and a gentleman doing refurbishment work, who were unsupervised working in all areas of the home, without any Criminal Records Bureau (CRB) or other employment checks. This matter was discussed with the manager and the owner and an immediate requirement was issued to address this matter with immediate effect. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 17 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): 19, 20, 21, 22, 23, 24, 25, 26 People who use this service experience adequate quality outcomes in this area. The physical environment generally meets the specific needs of the people who live here. There home has a major programme of decoration and refurbishment, which is on gong and remains work in progress at present. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home provides a clean and comfortable environment for the people who live here, however refurbishments and redecoration is work in progress at the moment. There are presently seven vacant rooms in this home, and all of these have had complete refits with an impressive finish. The manager advised us that the plan now is to move residents as and when they are ready, into Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 18 these rooms, enabling these refits to progress right through the home. Floors have been replaced and new carpets laid. The owners of this home are both general practitioners. One of them told us how they are presently doing evidence – based research in order to provide the most appropriate ‘dementia friendly’ environment possible. Rooms that are presently inhabited, are decorated and furnished to personal taste, and have photographs, ornaments and personal items that reflect the individual’s life history, with personal preferences taken into account. The home was clean and free from offensive odours throughout, and communal areas were generally comfortable and homely. Washroom facilities are numerous throughout the building, with clear, picture signage on the doors, to enable residents with cognitive impairment to identify these areas more easily. The home is surrounded by open gardens, which although presently cluttered in some areas, as expected, with rubbish from the refurbishments, will hopefully provide an inviting and safe outdoor area when the weather improves. At present this is not accessible to residents unless they are accompanied by staff. There is also a large expanse of land at the rear of the property, which the new owners are hoping to use to develop the homes’ facilities further in the future. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29, 30 People who use this service experience adequate quality outcomes in this area. This service recognises the importance of training and is in the process of delivering a programme that meets the National Minimum Standards. However there are some gaps in the recruitment process so that residents and staff may not always be protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There are presently seven vacant beds in this home, and therefore staffing levels have been adjusted accordingly. Currently there are three staff, plus the manager working during the day, and two staff working the night shift. There are laundry, kitchen and domestic staff that work Monday to Friday between 08:00 hours and 14:00 / 16:30 hours respectively. Therefore care staff are periodically still responsible for some non-care duties. However staff that we spoke to during this inspection did not express any concerns over this, and the owners informed us this is kept to a minimum. The manager and her deputy have also been working some shifts in order to cover sickness and minimise the use of agency staff wherever possible, so that continuity of care is maintained. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 20 We looked at the files of three staff, two had joined the team in the last eighteen months, and the third had been with the service for some years. Those that had been recruited by the present manager, had all the appropriate documentation in place, including fully completed application forms, references, CRB documentation, various forms of identification, and home office paper work where necessary. Those that had been recruited during her absence had not been so thorough, for example references were not always requested from previous employers. We also noticed that one member of staff from overseas, who had been TUPE from the previous company, did not have current documentation from the home office. She advised us that she had ‘Indefinite Leave’ to remain and work in this country. We requested that she bring this document in for the manager to check the following day. The Manager contacted us on the 18th of February to inform us that this member of staff had failed to produce the document as requested, and had infact resigned and left her post with immediate effect and no explanation. We suggested to the Manager that all staff files should be audited immediately. And we are confident that she will address this without delay. This process will include ensuring that volunteers and contract workers, who work unsupervised in the home, have an Enhanced CRB check. An immediate requirement was issued relating to this matter. The Responsible Individual for the service also contacted us to discuss the matter, and confirmed that a thorough check of staff files had taken place, and any omissions were being addressed as a matter of urgency. The manager told us that prior to the home changing hands last year, the training programme was ‘put on hold’ by the previous Providers, and this has left some staff over due with some basic/ mandatory training. The home has now employed the services of a new training provider, and there is a full programme in place to ensure that all staff have the opportunity to fulfil their training obligations, within the next three months. The care practices that we observed during this inspection were generally very positive. Staff were confident and competent in their roles and addressed the residents in a respectful way, and care and support was offered in an unhurried way. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 35, 36, 37 People who use this service experience adequate quality outcomes in this area. The manager is aware of the need to keep up to date with practice and continuously develop her own skills. Checks show that record keeping is generally up to date; however there are occasional omissions and entries are not always clear. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager at this home has been in post since before this home changed hands, and has worked hard to maintain a level of stability for both staff and Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 22 residents. She has completed her NVQ level 4, and told us she is keen to embark on the Registered Managers Award, or equivalent, as soon as possible, to ensure her management skills and knowledge are in line with present best practices. Her management style involves being visible and accessible to both staff and residents, however she told us that she is struggling to achieve this, as so much of her time is presently taken up with administrative duties. The allocated office area provides very limited space for her to work, and in addition appears to be used as a storage area. On the day of the inspection there were black bags with pressure cushions in them, bags of Easter Eggs in preparation for forthcoming festivities, and various other boxes of deliveries, taking up the limited space she has, this gave a generally disorganised impression. This home keeps personal allowance funds for each resident in the home with the exception of one or two. We looked at the account records for six residents. These were all up to date, and funds balanced with the records accurately. Receipts were present for all purchases and transactions. We looked at health and safety documentation, including the fire log and maintenance records. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis and water temperatures tested and recorded monthly. We viewed the maintenance log, which indicated that maintenance issues are being addressed in a timely fashion. Supervision records were examined, and indicated that staff are receiving some 1:1 sessions with the manager, however this is rather ‘hit and miss’ at the moment. We were also concerned that since the new owners took over the home, the manager is lacking any peer support or formal supervision. Accidents and incidents are being recorded and reported appropriately, and where necessary safeguarding referrals are being submitted. The manager in this home monitors the quality assurance, by internal auditing processes and by using questionnaires that are given to the residents and their representatives to complete. However she has not yet produced any sort of formal report relating to quality assurance. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 3 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 2 3 Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 15(2)(b) Requirement Care plans for the people living in this home must accurately reflect the current needs of the individual. People in this home should be consulted on and encouraged to participate in activities that suit their abilities. Any complaint relating to this home should be clearly documented. This must include copies of any investigatory actions, and letters of correspondence relating to the complaint. People who live in this home must be protected by the recruitment policy being strictly adhered to. People who live in this home must be cared for by staff that have been appropriately recruited. This must include all the information specified in paragraphs 1 to 7 of schedule 2, on every person employed in the home. Immediate Requirement issued. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 25 Timescale for action 31/03/09 2. OP12 16(2)(n) 31/03/09 3. OP16 22 28/02/09 4. OP18 13(6) 28/02/09 5. OP29 19(1) 20/02/09 6. OP30 18(1) 7. OP33 24 8. 9. OP36 OP37 18(2) 17 People who live in this home must be cared for by staff that have been appropriately trained to carry out their duties. A report must be submitted to CSCI that reflects how the quality of care for people living in this home is being reviewed and addressed. People who live in this home must be cared for by staff that are appropriately supervised. The records of people who live in this home must be maintained and kept up to date. 31/03/09 31/03/09 31/03/09 31/03/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP2 OP9 OP14 Good Practice Recommendations The home should consider reviewing contracts to ensure the information detailed is correct. The home should consider reviewing their system for auditing medication stocks, this may include a policy for medication, which needs to be returned or carried forward. The home should consider other ways of offering choices to residents with more severe cognitive impairment. Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Knoll House DS0000072747.V374208.R01.S.doc Version 5.2 Page 27 - 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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