Inspection on 16/01/07 for Korniloff

This inspection was carried out on 16th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Korniloff 09/09/09

Korniloff 22/07/08

Korniloff 18/01/08

Korniloff 15/06/06

Korniloff 30/09/05

Korniloff 12/04/05

Korniloff 10/11/04

Korniloff 06/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Korniloff Warren Road Bigbury-on-sea Kingsbridge Devon TQ7 4AZ Lead Inspector Graham Thomas Unannounced Inspection 16th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Korniloff DS0000003732.V310317.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. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Korniloff Address Warren Road Bigbury-on-sea Kingsbridge Devon TQ7 4AZ 01548 810222 F/P 01548 810222 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) Mrs Georgina Suzanne Phillips Mrs Georgina Suzanne Phillips Care Home 17 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (17), Physical disability (17) of places Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2006 Brief Description of the Service: Korniloff is situated in Bigbury on Sea and has extensive sea views. The home is registered to provide care for 17 older people who may also have physical disabilities or dementia. The accommodation comprises 11 single and 3 double rooms. All of the rooms are currently used as single accommodation. Since the last inspection, one room has been fitted with en-suite toilet facilities. The property is a detached three storey building with the bedrooms situated on the lower ground floor and the first floor These can be accessed by two chair lifts. There are 3 spacious lounges and a dining room. Contact with the local village is maintained through regular social events. Fees for accommodation at Korniloff range from £306 to £450 per week. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the inspection, the Registered Providers returned a pre-inspection questionnaire. During the inspection, the Inspector toured the whole premises. Six service users, five staff and a visiting professional spoke with the Inspector. Management issues were discussed with senior staff and the Registered Providers. A sample of six care plans was examined. Staff files and other records were also sampled. The home’s system for the administration of medication was inspected. What the service does well: • • Visitors to Korniloff are made welcome. Regular social events help service users to keep in touch with friends, family and the local community. Staff help service users to keep healthy by maintaining good links with health professionals. Advice given by these professionals is promptly acted upon. Service users’ individual routines and preferences are respected by staff • What has improved since the last inspection? • • • • • The care and support of service users can now be more effectively monitored and planned because care plans are better organised. Staff have now had the training they need to properly protect service users from abuse. One room has been upgraded to include an en-suite toilet. Another is being refurbished. Lockable storage is now available to all service users in their rooms Fire records are kept up to date and hazardous substances are more safely stored Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 6 What they could do better: • • • • • Service users need to be informed before they move in that the sun lounge may not always be available Service users should receive written confirmation that the home will meet their needs before they move in. Service users need to be more involved with their individual plans The system for administering medicines needs to be made safer for service users Improvements are needed to make the home safer and more comfortable. For example, the Registered Provider must make sure that hot water is safe in the way it is supplied and used. The odour on the lower ground floor should be eliminated. Suitable locks need to be fitted to service users’ rooms. Service users’ convenience and safety should be improved by staff who are awake at night. The home’s policy on protecting service users from abuse needs to be changed to make sure service users are properly protected. A monitoring and planning system is needed to ensure that the quality of the service keeps improving • • • 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. Korniloff DS0000003732.V310317.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 Korniloff DS0000003732.V310317.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6: Quality in this outcome area is adequate. There is not sufficient confirmation for prospective service users that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A total of six service users’ files were examined. These included the most recently admitted service users. All contained an assessment of the individual’s needs. The date recorded on these assessments was the same as the admission date. Mrs. Phillips stated that the assessments had been done prior to admission and written up on the day the service user moved in. It is recommended that the actual date of assessment should be recorded on these forms. This would provide clarity if there were any subsequent queries about the process. The Registered Provider had not written to recently admitted service users to confirm that the home could meet their needs. This was a requirement at the last inspection. Korniloff does not admit service users who require only intermediate care. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 9 Korniloff DS0000003732.V310317.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10: Quality in this outcome area is good. Service users can feel confident that their personal and health care needs will be sufficiently well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of six care plans was examined. Since the last inspection, there had been a significant improvement in the organisation and content of the plans. Each plan contained assessments made by the home and/or the referring authority. Individual needs regarding health, personal care, family and social contact were clearly identified. The plans showed evidence of regular review and changes had been made to the plans in response to changing individual needs. For example, one plan showed a change in the physical support for one service user whose mobility had deteriorated. One plan contained a useful personal profile which described the experiences tastes and personality of the individual. The Inspector discussed with senior staff the possibility of producing a similar profile for all service users. There was also discussion about how service users and/or their representatives might be more involved in the plans. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 11 In addition to the plans, a profile of immediate care needs was kept in service users’ rooms. There were also individual daily diaries. The Inspector noted that recording in the daily diaries had improved to include a more detailed account of the individual’s daily experience. Evidence was seen that the home monitored and promoted good health. For instance, All the service users’ records included regular weight monitoring. The home’s activities programme also included exercise such as armchair aerobics. The individual plans showed evidence of both routine and specialist health care. Service users confirmed that they had access to the doctor as required or on request. Visits by healthcare professionals were confirmed in individual daily diaries. A visiting chiropodist stated that the home always followed professional advice. For example, on the day of the inspection, one service user’s slippers were exchanged immediately when her existing pair were identified as a problem. This visitor confirmed that service users were generally well supported to maintain a satisfactory standard of personal hygiene. The home’s system for the administration of medicines was examined. Some service users were administering all or some of their own medication. Risk assessments had been produced for these service users. Lockable storage was available for medication in their rooms. Korniloff has a dedicated “treatment room” in which medication was securely stored. This storage had been improved to include separate secure storage for controlled drugs. A separate refrigerator was available specifically for medicines requiring cool storage. One controlled drug was appropriately stored though this had not been used at the time of the inspection. This medication was prescribed “as required”. It is recommended that clear guidance should be produced concerning the use of this medicine. This should include the circumstances under which it is to be administered and the maximum dose. Records now include pictures of service users to reduce possible errors, as discussed at the previous inspection. Sample signatures were also available for reference. Medicines administration records were mostly up to date and in good order. However, in one instance signatures were missing on the record. The senior carer with responsibility for this area was able to identify the source of the errors. Staff training in the use of medicines comprises of a general awareness training during induction. Those staff who go on to administer medicines are trained and observed by senior staff. Some suggested improvements to the recording of this activity were discussed during the inspection. Further specific training is also undertaken with the supplying Pharmacy. The service users with whom the Inspector spoke felt that their privacy and dignity was respected by staff. During the inspection treatment was taking Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 12 place in the home’s treatment room behind further screening. Service users confirmed that they were able to receive professional and other visitors in private if they wished. Preferred forms of address are recorded in individual plans and were being used by staff during the inspection. Korniloff DS0000003732.V310317.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): Standards 12-15: Quality in this outcome area is good Service users are well supported to pursue their own routines and preferred activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users confirmed that the lifestyle in the home remains flexible. Preferred individual routines were identified in the care plan profiles in each room. During the inspection some service users spent time in their rooms whilst others joined small groups in the home’s communal areas. In discussion, the staff were aware of individual preferences and routines. Visiting arrangements remained open and flexible. One service user, for example, was being visited daily by her husband who lived nearby and taken for trips in the car. Other service users stated that their visitors were always made welcome and could visit at any time. A programme of activities was in place at the time of this inspection. Detailed and up-to-date records of service users’ participation in these activities were seen. The activities included visiting entertainers, as well as games organised by the home’s staff. Service users confirmed that they could choose whether or not to join these activities. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 14 Most service users have lived in the locality. Contact with the local village is maintained through monthly charity coffee mornings held at the home. A Parish magazine was seen advertising these occasions. On the second day of the inspection a Communion service was held. Service users confirmed that this is a regular event which is also attended by friends from the village. Discussion with staff and service users and examination of individual plans showed a number of ways in which personal autonomy and choice is maintained. As stated, individual routines and preferences are detailed in the plans. Where possible, service users were being supported to take responsibility for all or some of their medication. An examination of individual financial arrangements showed that these were managed by service users where possible, or their relatives Individual rooms contained with many personal items including some furniture. Menus were examined and the kitchen was inspected. During this inspection meals were being prepared by the Registered Providers and staff. One cook was employed for three days and another was being sought for the remainder of the week. Individual dietary requirements were seen in care plans and staff were aware of these and had an understanding of their importance. Meals were taken in the home’s dining room or in individual rooms. A menu was on display in the home’s pleasant and congenial dining room. On the first day of the inspection, service users were seen taking breakfast at different times according to their individual routines. Each was offered a choice of where they took their breakfast and what they might have. Further choice was available at lunch time. The choice at lunch time had been extended since the last inspection. The meals seen were attractively presented and included freshly prepared and cooked ingredients. Staff were seen offering discreet assistance to service users. Korniloff DS0000003732.V310317.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): Standards 16 and 18: Quality in this outcome area is good. Service users can feel confident that their concerns will be listened to and any allegations of abuse will be appropriately handled. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure which is accessible to service users and their relatives / friends. This included details of how to contact the Commission directly. A complaints record was held in the home. No complaints were recorded. The Commission had received no complaints about the home. A policy on the protection of vulnerable adults was seen. This had yet to be amended as recommended at the last inspection. The policy stated that the manager should investigate if abuse is disclosed. It should be amended to conform with national and local guidance. This is important because if the current procedure were to be followed, it might undermine any potential criminal investigation. A copy of the current local guidance had been obtained and the Assistant Manager stated that this would form the basis of the revised policy and procedure for the home. Since the last inspection, all existing staff had received training in the protection of vulnerable adults from abuse. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 24, and 26: Quality in this outcome area is adequate. Service users have benefited from some improvements to the home’s environment. However, further work is required so that service users can be assured of living in a safe and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this inspection the Inspector made a complete tour of the premises and examined the available maintenance records. Accommodation at Korniloff is set out over three floors with access provided by two chair lifts. The ample communal space includes two lounges, a sun lounge, a bar and separate seating area and a dining room. All of these areas were comfortably furnished in a homely style. The large lounge was still awaiting redecoration. The Registered Provider stated that this would commence imminently, starting with the replacement of the ceiling. Other outstanding work on the décor, lighting and the replacement of the carpet in this area could then be undertaken. Following a management review of the service by the Commission, it has been agreed that the timescales now set for the completion of this work would be final. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 17 As the home has ample communal space, it was agreed at this inspection that the outstanding requirement to connect heating in the sun lounge would be dropped. Instead, the home must amend its statement of purpose and service user guide to indicate that this area is not available for use in cold weather. The Registered Provider was advised that the left hand door to this area was stiff as it was rubbing against the carpet. There are communal bathrooms and toilets on the lower ground floor and the first floor. Toilet facilities are also situated near the communal areas on the ground floor. The bathroom on the first floor has an assisted “Parker” bath. All rooms have wash hand basins. The cracked basin in bedroom two had been removed and the room was being refurbished. One other room had been fully refurbished since the last inspection and upgraded to provide en-suite toilet facilities. Adaptations and aids were available in toilets such as toilet frames and booster seats. These were in good condition. Risk assessments concerning the unregulated hot water supplied to hand basins had not yet been produced. This was the subject of an immediate requirement notice. Regulation of hot water to the baths was discussed with the Registered Providers at the Commission’s management review and at this inspection. It was agreed that a final timescale of 2 months would be set for the regulation of the hot water supply to the bath upstairs. Difficulties in the arrangement of the hot water supply to the bath on the lower ground floor means that regulator valves cannot practicably be fitted. Requirements concerning the hot water supply to this bath have therefore been modified. At the time of this inspection all of the individual rooms were singly occupied. All the rooms visited were individually and comfortably decorated and furnished. Many individual possessions were in evidence including some items of furniture which had been brought to the home. Adaptations were seen in some rooms such as raised beds and cot sides. Since the last inspection lockable storage had been provided in each room. Suitable locks had yet to be fitted to all the doors to these rooms. The Registered Provider had obtained one lock for discussion with the Inspector. It was agreed that this lock type would meet the requirements of both safety and privacy. Infection control measures were examined. All communal wash hand basins were supplied with liquid soap and towels. The home’s laundry is sited away from food preparation areas. The laundry had its own hand washing facilities with liquid soap. Staff stated that the washing machine used for heavily soiled laundry had the required programming ability for hot washing. There was no sluicing facility. Staff were seen wearing protective clothing when handling infected materials. One service user’s skin cream was found in the room of another service user. Other skin creams in service users’ rooms were found without labels. An unlabelled cream was found in the ground floor communal toilet. Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 18 All areas of the home were found to be adequately warm during the inspection with the exception of the sun lounge (see above). All radiators in individual rooms and most in communal areas were covered. Those radiators not covered were not accessible to service users. All areas were clean and the upper two floors were free from offensive odours. There was, however, a strong odour on the lower ground floor. This attracted negative comments from service users in conversation with the Inspector. Korniloff DS0000003732.V310317.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): Standards 27 to 30: Quality in this outcome area is adequate. There are sufficient numbers of experienced and trained staff to meet service users’ immediate needs. However, service users’ quality of life could be enhanced by improvements in the home’s staffing arrangements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Inspection of staff files and discussion with staff indicated a satisfactory recruitment process. This included formal application, criminal records checks and two references which had been followed up. Rotas were examined and discussed with the Assistant Manager and the Registered Provider. Staffing arrangements in the home were as follows. Mrs Phillips, the Registered Provider provides administrative support and caring cover. Mr. Phillips undertakes the maintenance of the home and occasional cooking. There were two senior carers who provide day to day supervision of the care staff. An Assistant Manager undertakes some caring as well as supervisory, administrative and management duties. A part time cook covers three days per week. Mrs. Phillips stated that advertisements for another part time cook to cover the remaining days had not so far attracted a candidate. The home was staffed at night by the Registered Provider (who lives on the premises) and one member of staff sleeping in. The Assistant Manager stated that waking night staff were provided when required (for example, when a Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 20 service user was ill). The Inspector believed that this did not sufficiently cater for the possibility of accidents and emergencies at night. At the time of the inspection there were eleven service users resident in the home. On the morning of first day of the inspection the home was staffed by a senior carer and two others. One of these had been recruited in the previous two months. Many of the service users at Korniloff enjoyed a relatively high degree of independence. There appeared to be sufficient staff during the inspection to provide adequate care and support to the service users in residence at the time. At this inspection, approximately 33 of staff involved directly in caring held a National Vocational Qualification in care at level 2 or above. One senior carer held a level 3 qualification and was planning to undertake an assessors award. The Assistant Manager was close to completing the Registered Managers Award. The Assistant Manager stated that two more care staff were about to undertake an NVQ qualification as part of the developing training plan. The Assistant Manager had produced staff training plans and discussed with the Inspector how these were to be linked to staff supervision. The newest staff members had undergone induction training and all had received training in the protection of vulnerable adults from abuse. The Registered Provider stated that the home’s staff join other homes in the locality for some short courses. Some staff were attending a short course on dementia on the second day of this inspection. Korniloff DS0000003732.V310317.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): Standards 31, 33, 35 and 38: Quality in this outcome area is adequate. Improvements in the service seen since the last inspection indicate that the service is now adequately managed for the benefit of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Phillips retains overall control of the home. Management tasks are shared with an Assistant Manager. The Assistant Manager is undertaking the Registered Managers Award which she is close to completing. Two senior carers oversee the day to day work of the home’s Care Assistants. It remains a recommendation that the Assistant Manager should be Registered with the Commission as Manager of the home. The Inspector discussed the home’s system of quality assurance with the Registered Provider and the Assistant Manager. It was evident from these Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 22 discussions that a systematic approach to the continual improvement of the service has yet to be developed. The Registered Provider stated that service users’ financial affairs were handled by families or other representatives independent of the home. Small amounts of cash were held for individuals. Records were examined concerning transactions made with this cash. Full records were kept for each service user and these were supported by receipts for purchases such as hairdressing and chiropody services. These records could be cross-referenced with service users’ daily diaries. Health and safety issues in the home were examined. The training of staff in health and safety topics and the necessary updates to this training were being identified in the new training plans. The home’s fire log showed regular maintenance of equipment, fire training and drills. A safety certificate was seen dated January 2007 concerning the testing of portable appliances. Other records were seen relating to the maintenance of the stair lift and hoists. Infection control measures were examined. Staff were seen wearing protective clothing when handling infected material. Liquid soap and towels were provided at all communal hand basins. Staff told the Inspector that the washing machine used for soiled clothing had a hot wash cycle. There was no sluice in the laundry. Arrangements were in place for the disposal of clinical waste. Some skin creams were found unlabelled in service users’ rooms and one was found in a communal toilet. Skin cream prescribed for one service user was found in the room of another. This presents a risk of cross infection if the creams are used by more than one person. Legionella testing had been conducted. Risk assessments had yet to be produced concerning the supply of unregulated hot water to hand basins. This was the subject of an immediate requirement. The hot water supply to the bath on the first floor had yet to be regulated. Following discussions regarding the lower ground floor water supply it was agreed that a full risk assessment and management plan should be implemented. Hazardous substances were securely stored when not in use and data sheets were held concerning these substances. Korniloff DS0000003732.V310317.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 x x x 2 x 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 24 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 Standard OP3 Regulation 14(1)(a) to (d) Requirement “The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so— ….. (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare” (This requirement has been revised following a management review. Part (d) has been the subject of previous requirements where timescales have not been met. The timescale set on this occasion must be regarded as final) Timescale for action 16/02/07 2 OP9 13(2) “The registered person shall 16/02/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.” DS0000003732.V310317.R01.S.doc Version 5.2 Page 25 Korniloff In particular, (a) guidelines must be produced for all medication prescribed “as required” these guidelines must include the circumstances in which the medication is to be given and the maximum dose, (b) skin creams must only be used by the service user for whom they are prescribed, (c) The Medicines Administration Record must be completed at the time the medicine is administered (This requirement has been revised following a management review. Part (b) has been the subject of previous requirements where timescales have not been met. The timescale set on this occasion must be regarded as final) 3 OP19 4(1)(b) “The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of…… ….(b) a statement as to the facilities and services which are to be provided by the registered person for service users.” In particular, the home’s statement of purpose must be modified to explain that the sun lounge is not heated and therefore may not be available for use at all times. “The registered person shall ensure that…. …. (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated” In particular, risk assessments DS0000003732.V310317.R01.S.doc 16/03/07 4 OP19 13(4)(c) 24/01/07 Korniloff Version 5.2 Page 26 must be produced regarding the unregulated supply of hot water to hand basins. The Registered Provider must confirm in writing to the Commission that this has been done. (This was the subject of an immediate requirement notice) 5 OP19 13(4)(c) “The registered person shall ensure that…. …. (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated” In particular, risk assessments and a risk management plan must be produced concerning the use of the bath on the lower ground floor. “The registered person shall ensure that…. …. (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety” In particular, the hot water supply to the bath on the first floor must be regulated so that water is supplied at or close to 43oC. (This requirement has been revised following a management review. It has been the subject of previous requirements where timescales have not been met. The timescale set on this occasion must be regarded as final) 16/02/07 6 OP19 13(4)(a) 16/03/07 7 OP20 23(2)(d) and (p) “The registered person shall 16/01/08 having regard to the number and needs of the service users ensure that….. DS0000003732.V310317.R01.S.doc Version 5.2 Page 27 Korniloff ….(d) all parts of the care home are kept clean and reasonably decorated…. ….(p) ventilation, heating and lighting suitable for service users is provided in all parts of the care home which are used by service users.” In particular, the main lounge must be redecorated and a new carpet fitted. The lighting must be improved in this room. (This requirement has been revised following a management review. It has been the subject of previous requirements where timescales have not been met. The timescale set on this occasion must be regarded as final) 8 OP24 12(4)(a) 16/01/08 “The registered person shall make suitable arrangements to ensure that the care home is conducted…. ….(a) in a manner which respects the privacy and dignity of service users” In particular, service users’ rooms must be fitted with locks and service users offered a key unless sufficient reasons for not offering this service are recorded in the care plan. Locks must be lockable from the inside and capable of being overridden in an emergency. (Previous Timescale 31/01/07 not met) Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 28 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 Registered Provider should enable service users and/or their representatives to become involved in forming and reviewing their individual plans The home’s policy concerning the protection of vulnerable adults from abuse should be amended to confirm with local and national guidance. The Registered Provider should install a sluicing facility The offensive odour on the lower ground floor should be eliminated The registered provider should ensure that there is at least one member of staff on waking night duty every night. The Registered Manager should appoint a qualified Registered Manager The Registered Provider should develop a system for monitoring the quality of service provided to service users. This should be linked to an annual development plan. 2 OP18 3 4 5 6 7 OP26 OP26 OP27 OP31 OP33 Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Korniloff DS0000003732.V310317.R01.S.doc Version 5.2 Page 30 - 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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