Inspection on 21/09/05 for Laburnum Court

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Laburnum Court 24/10/07

Laburnum Court 04/10/06

Laburnum Court 05/05/06

Laburnum Court 02/12/05

Laburnum Court 14/02/05

Laburnum Court 29/07/04

Laburnum Court 09/02/04

Laburnum Court 22/07/03

Laburnum Court 30/07/02

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

CARE HOMES FOR OLDER PEOPLE Laburnum Court Priory Grove Lower Broughton Salford M7 2HT Lead Inspector Sylvia Brown Unannounced Inspection 21st September 2005 07:45 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 Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Laburnum Court Address Priory Grove Lower Broughton Salford M7 2HT 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) 0161 708 0171 0161 705 0156 Southern Cross Healthcare Services Limited Marcella Ann Lade Care Home 67 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (37) of places Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Minimum nursing staffing levels as specified in the notice issued under Section 25(3) of the Registered Homes Act 1984 on 10 December 1999 shall be maintained. Up to 17 service users requiring personal care only may be accommodated on the first floor. The person in charge of the first floor unit caring for people with general nursing needs must be registered on Part 1 or 12 of the Nursing and Midwifery Council register. Service users admitted to the unit caring for people with dementia shall not be subject to detention under the terms of the Mental Health Act 1983. The person in charge of the unit on the ground floor for people with dementia must be registered on Part 3 or 13 of the Nursing and Midwifery Council register. The home must at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. 14th February 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Laburnum Court’s registered provider is Southern Cross Healthcare Services Limited. The home has a new manager, who had previously been registered with the Commission in other areas. She has applied for registration of this home and the CSCI is awaiting references prior to processing the application. Laburnum Court is a purpose built facility on two floors. The first floor of the building is registered to provide accommodation for 37 older people, up to 17 of who will need personal care only. The ground floor provides accommodation for up to 30 older people whose nursing needs are primarily due to mental ill health. Accommodation is provided in single en suite bedrooms with a variety of communal space for the residents to use. The home is situated in Broughton, a residential area of Salford, close to local shops and within a bus ride of Salford’s shopping precinct. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Laburnum Court was unannounced and was undertaken over two days, commencing at 7:45am on the first day and 7:00am on the second day, with a total of 14 hours spent on the premises. At the time of the inspection the registered manager was on holiday. On the second day the deputy manager was on the premises as was by prior arrangement the operations director. The inspector feedback at the end of the inspection and issued two immediate requirements. The inspector had the opportunity of sitting with residents and sharing three meal times with them. Residents and relatives’ comment cards were left at the home. At the time of writing the report three had been received; the comments of which have been included within the report. Feedback was provided at the end of the inspection to the operations manager and deputy officer regarding the outcome of the inspection, and requirements and recommendations made. What the service does well: What has improved since the last inspection? This was the first time the inspector had inspected Laburnum Court. This, and the absence of the registered manager, limited identification of all the developments made since the last inspection. The home’s Statement of Purpose and Service User Guide have been amended and include up to date information. The company is in the process of introducing a new care plan file, which should improve how information is gathered and increases the involvement by the resident and/or their next-ofkin. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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 Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Prospective residents receive information about the home, have their needs assessed and are able to visit prior to making any decisions about their future. EVIDENCE: Two residents’ files were evaluated. Both files contained assessments of need completed by the placing authority and the home. Both residents had received contracts from the local authority, however the more detailed terms and conditions of residency provided by the company were not evident. Files did not contain letters of confirmation which state that a place is offered or that the home can meet the assessed needs of the residents. Though residents spoken to could not confirm that they had visited the home prior to admission, staff stated that visits are offered to prospective residents. Some decline the offer, whilst others and/or their relative visit the home prior to moving in to have a look around and view a room. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Staff failed to safely maintain, manage, administer, record, store and dispose of medicines. EVIDENCE: New care planning records were being introduced at the time of the inspection. The new formats include mapping of wounds and consultation with residents and/or next of kin regarding the development of the care plan and its approval. The inspector was informed that there were no residents with pressure sores and that specialist equipment is provided to those who require additional support. Throughout the home notices were displayed relating to staff break times. In addition, one dining room displayed notices regarding residents’ care and assistance required. Such practice is institutionalised and reduces the privacy and dignity of residents. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 10 The manner in which all three units managed, administered, stored, recorded and disposed of medication was evaluated. All units failed to maintain the appropriate standard. Medication administration records contained signature omissions for medication which had been administered. Staff were observed signing medication administration records collectively, rather than when it was administered to the individual. Prescribed medication times were not adhered to. Observations were that administration commenced two hours later than prescribed. The second administration commenced on time, culminating in only a two hour period between dosages being received. Records failed to identify the actual time medication was administered. Medication that required refrigeration was found in administration trolleys which exceeded the required storage temperature. Medication which had a use-by date once opened, failed to identify an opening date. Staff with responsibility for medication management confirmed that they did not consistently record medication to be disposed of. Medication no longer required was managed in an ad-hoc and disorganised manner. Medication awaiting collection had become separated from its prescribed container, culminating in liquid medication leaking and tablets becoming loose. When asked, they stated that no one person had responsibility for the management and storage of medicines within the home or its return to the pharmacist. Medication was observed to be awaiting collection for disposal for a resident who had died two days prior to the inspection. Staff were unaware that such medication should be retained on the premises for seven days. One member of staff who had the responsibility for administering medication could not remember having received training in the management and administration of medication. Evaluation of the staff member’s file failed to confirm that training had been undertaken. So serious was the home’s failings in respect of medication management and, as a consequence, the potential risk to residents, an immediate action requirement was issued to the regional manager. The registered person also received a serious concerns letter. Subsequent to the publishing of this report, a pharmacy inspector from the CSCI was deployed to the home to further evaluate practices. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 11 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 Service users have limited chance to maintain choice and control over their lives. There is minimal opportunity for them to visit the outside community or have appropriate social stimulation to meet their individual needs. EVIDENCE: Three residents stated there was little to do within the home. Though one appeared accepting of the situation, the others wished to undertake more activities. One resident stated they longed to go outside and see what was going on. Notices within the home stated that bingo, dominoes and singing were regularly provided for residents’ enjoyment, however staff were vague when asked about the activities and the activities co-ordinator explained that she was new to the post and had yet to organise a structured programme. Staff on the Priory Unit stated they had not received specialist training to meet the social needs of or occupy people with mental health and/or dementia. Records failed to demonstrate how the social needs of the residents were met. Care files had incomplete social profiles and residents’ preferred hobbies or pastimes when moving into the home were not routinely sought. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 12 Relatives’ comment cards confirmed that they are made to feel welcome when visiting and are kept informed of their relatives’ changing needs. Routines within the home limit residents from making their own decisions and choices. Mealtimes and the serving of drinks are carried out at the same time on all units. Though residents may wake early, there are no consistent procedures to provide them with hot drinks when they wake or whilst preparing for the day. Staff on two units confirmed that staff “did their own thing”, some providing drinks through the night and early morning, whilst others did not. The inspector observed that some residents were not assisted to rise until after 9:30am; staff stated that residents were awake but unfortunately had to wait for assistance. A staff member pointed out that one resident, who had just independently risen, had not been supported the previous night into her nightwear. Continuing, the staff member stated that the resident required support to dress and undress and was dressed in the same clothes that she herself had put on the service user the day before. Residents independently rising were observed sitting unsupervised for lengthy periods of time waiting for their breakfast or their first morning drinks. The absence of staff for some was confusing and a cause for concern. Breakfast offered limited choice. Cereals and toast are served each day with staff preparing the meal without consulting residents. When asked, staff stated residents enjoyed the same each day. Residents told the inspector that they would like to have eggs and bacon as a choice. One resident stated she enjoys the egg and bacon breakfast served on a Sunday and would like something like it during the week. A number of residents are not able to make informed choice; consequently, staff order meal options on their behalf. There was no system of referral to check what meals had previously been served to ensure that meal options differed. The meal request for ‘soft diet’ was repeatedly recorded for some residents. There were no details as to what ‘soft’ food option was being requested or on offer or what was actually served. After evaluation the inspector identified that thee consecutive meals served consisted of minced beef or lamb. One resident was observed receiving an omelette rather than the meat meals on offer. Staff stated that due to the resident’s religion, he was not permitted certain foods. The inspector could not identify that specialist advice had been sought regarding the resident’s preferred food or that arrangements had been made to acquire permitted food from specialist suppliers. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 13 Although the main cook took pride in his work and residents and staff spoke favourably of him, he confirmed that he had not received training in the preparation of special diets and meals. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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 Complaints received were not recorded. Residents confirmed they felt safe. EVIDENCE: Since the last inspection the CSCI has received one complaint regarding services at the home. During the course of the inspection the inspector became aware of another complaint that had been raised by a resident’s relative. Inspection of the home’s complaint record failed to identify that any complaints had been received. Comment cards confirmed that relatives are aware of the home’s complaint procedure. Of the three comment cards received, none had made a complaint about the service. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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, 20, 21, 25 & 26 Residents do not live in clean and well maintained accommodation. EVIDENCE: There were strong odours in parts of the home. Paintwork was badly scratched and damaged, and wallpaper was marked and torn in places. Windowsills and paintwork were dirty, carpets stained and kitchenette facilities inadequate. There were insufficient worktops in the kitchenettes, culminating in crockery and cutlery being on display at all times. Observation of staff practices identified that infection control procedures were not followed or known. On the first morning of the inspection a member of staff answered the main door wearing plastic gloves used whilst assisting residents. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 16 Bags containing soiled items were open in the laundry area. Soiled quilts and pillows were also observed in the laundry area, uncovered and exposed. Staff in the laundry did not have appropriate disposable gloves or aprons and, when asked, staff on the units and in the laundry stated that they had not received infection control training. On the Priory Unit one resident was observed by the inspector to finger and lick all food items within the unit’s refrigerator and put them back undetected. The inspector drew this matter to the attention of staff. The flooring in toilet/shower room, G1, was split which increases the risk of accidents to residents and minimises infection control procedures. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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 Robust recruitment procedures were not in place. Staff required essential training and were not deployed in numbers to meet the needs of and supervise residents at all times. EVIDENCE: One relative’s comment card stated “I find no fault with the care or any of the staff”. However, staffing levels and the inappropriate deployment of staff have failed to ensure residents receive timely support and supervision or ensure the cleanliness of the home. Two staff were deployed on the residential unit. Residents were observed to be rising and having to wait for drinks and breakfast unattended in the dining room whist staff were supporting others. Staff confirmed that residents were awake in their bedrooms and were waiting for support. The inspector was informed that of the 11 residents on the unit, four required two to assist them, whilst another five required one to one support. There was no increase in staff at peak periods. Observations on the Priory Unit identified that whilst these residents required constant supervision, there were times in the day when they were left for long periods of time without supervision, particularly at handover periods. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 18 As previously stated, the inspector observed one resident fingering and licking food items within the refrigerator and then putting them back, undetected by staff. The inspector drew this matter to the attention of staff. Three newly employed staff files were evaluated. Recruitment and selection procedures were not followed. Two files did not contain a current photograph, references, letter of appointment or contract of employment. A requirement was issued regarding these matters at the previous inspection and are again repeated. Staff were vague about their completed training, some stating they had not received moving and handling training, others basic food hygiene and first aid. Staff files indicated that some training had been undertaken but was out of date and updated training was required. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 19 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, 36 & 38 Effective routine management systems are not in place and, as a consequence, residents receive inconsistent levels of care EVIDENCE: Since the last inspection the manager has completed the registration process with the CSCI. At the time of the inspection, she was not in attendance at the home. Staff stated that they felt supported by the manager and that she visited the units each day. Not withstanding the information received, it was evident throughout the inspection that the manager has yet to implement management strategies which ensure that standards are maintained appropriately. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 20 Throughout the inspection it was evident that each staff team worked in isolation, in that, staff gave personal answers regarding how they met residents’ needs and appeared unaware of formal management systems or routines. Evaluation of staffing records failed to identify that formal supervision was undertaken. Staff confirmed that they had not received formal supervision. During the inspection staff were not observed to be supervised or provide with guidance by senior members of staff. Staff were unclear as to the action to be taken in the event of a fire emergency. Evaluation of fire safety records failed to confirm that all levels of staff employed within the home had received practical fire drill training within the past six months. An immediate requirement was made and a serious concerns letter was sent to the registered person regarding this matter. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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 3 2 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 1 1 3 X X X 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 1 X X X X 1 X 1 Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 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 Standard OP2 Regulation Sch 4(8) Requirement The registered person must ensure that residents receive a full terms and conditions of residency at the point of admission and that signatures of agreement are obtained. The registered person must ensure that all staff with responsibility for medication administration and management receive up-to-date appropriate training, are competent to complete the tasks required and are aware of the home’s medication procedures, the Royal Pharmaceutical Society’s guidance and that registered nurses adhere to UKCC standards at all times. The registered person must ensure that all staff with responsibility for medication administration and management sign for medication administered contemporaneously. The registered person must ensure that all staff with responsibility for medication administration and management DS0000006734.V249715.R01.S.doc Timescale for action 01/01/06 2 OP9 13(2) 21/09/05 3 OP9 13(2) 21/09/05 4 OP9 13(2) 21/09/05 Laburnum Court Version 5.0 Page 23 5 OP9 13(2) 6 OP9 13(2) 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 OP10 12(4)(a) administer medication at prescribed times. Where administration differs, accurate times must be recorded. The registered person must ensure that all staff with responsibility for mediation administration and management ensure that prescribed medication is available on the premises. The registered person must ensure that all staff with responsibility for medication administration and management ensure medication is stored as required. The registered person must ensure that all staff with responsibility for medication administration and management ensure that medication no longer required is disposed of appropriately and that records of all returned medication are maintained. The registered person must ensure that all staff with responsibility for medication administration and management ensure that once medication with a use-by date is opened, the date is recorded. The registered person must ensure that all staff with responsibility for medication administration and management know of their responsibility to retain medication on the premises for seven days after the death of a service user. The registered person must respect and ensure residents’ privacy. Remove all notices displayed in the home relating to the care and support of residents and staff practice. DS0000006734.V249715.R01.S.doc 21/09/05 21/09/05 21/09/05 21/09/05 21/09/05 31/10/05 Laburnum Court Version 5.0 Page 24 11 OP12 16(2)(m) 12 OP12 16(2)(m) The registered person must consult with specialists and train staff regarding the daytime occupation and socialisation of residents with mental frailty, dementia and challenging behaviour. The registered person must provide the variety of social activities stated in the organisation’s literature, statement of purpose and service user guide, including visits to outside places of interest and community involvement. The registered person must introduce systems that ensure residents are offered and receive drinks whenever they wish, including night-time, early morning and when rising. The registered person must ensure that residents are supported to make decisions and choices, and that staff respect and support those decisions, including rising and retiring routines. 15/01/06 15/12/05 13 OP14 12(2) 16(2)(i) 01/11/05 14 OP14 12(2) 01/11/05 15 OP15 16(2)(i) The registered person must 01/11/05 ensure that residents are offered choice at all mealtimes, including specialist requirements and requests. The registered person must ensure that those with responsibility for preparing meals, including specialist diets, are appropriately trained, qualified and competent for the work they are to perform. The registered person must record all complaints, investigations and outcomes. DS0000006734.V249715.R01.S.doc 16 OP15OP27 18(1)(i) 01/11/05 17 OP16 22 01/11/05 Laburnum Court Version 5.0 Page 25 18 OP19 23(1)(a) (b) 19 OP19OP26 18(1)(i) 20 OP20 23 21 22 OP26 OP27 16(2)(k) 18(1)(a) 23 OP29 19, Sch 2 24 OP30 18(1)(i) 25 26 OP36 OP38 18(2) 23(4) The garden at the side of the property, accessed via the EMI Unit French windows must be made safe prior to allowing service users access to this area. (Previous timescale of 14/06/05 not met). The registered manager must ensure staff receive training in infection control and that stringent infection control procedures are implemented. The registered person must complete a full audit of the premises and supply the CSCI with an action plan to upgrade the homes in all areas to meet required safe and hygienic standards. The registered person must eradicate offensive odours within the building. The registered person must ensure there are sufficient staff to supervise residents and meet their needs, and maintain a clean environment. Staff personnel files did not include photographs and two references in all cases and this must be addressed. (Previous timescale of 14/04/05 not met). The registered person must ensure that staff are appropriately trained, including moving and handling, first aid, adult abuse and complaints. The registered person must ensure formal supervision is in place for all levels of staff. The registered person must ensure that all staff have received up-to-date practical fire drill training and are aware of the actions to be taken in the event of a fire emergency. 15/11/05 15/12/05 01/01/06 15/11/05 31/10/05 31/10/05 01/02/05 15/11/05 01/11/05 Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 26 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 OP4 OP12 OP31 Good Practice Recommendations The registered person should ensure that residents receive confirmation of placement and that the home is able to meet their assessed needs. The registered person should ensure that information is sought regarding residents’ hobbies and preferred social activities at the point of admission and ongoing. The registered person must ensure that management strategies are developed to provide a consistent service to residents which meet required standards. Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Laburnum Court DS0000006734.V249715.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!