CARE HOMES FOR OLDER PEOPLE
Laburnum Court Priory Grove Lower Broughton Salford M7 2HT Lead Inspector
Sylvia Brown Unannounced Inspection 24th October 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Laburnum Court DS0000006734.V348553.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. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 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 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd vacant post Care Home 67 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (29), Old age, not falling within any other of places category (37) Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. 7. One named service user who is below 65 years of age is accommodated on the EMI unit. When this service user leaves, the category will revert back to DE(E). 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. The person in charge of the unit on the ground floor caring for people with dementia must be registered on Part 3 or 13 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. 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. The home must at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. 20th March 2007 Date of last inspection Brief Description of the Service: Laburnum Court is a large, purpose built care home that provides a accommodation on two floors. Bedrooms are single with en-suites, which gives service users increased privacy. There are a number of seating areas where service users can meet and socialise. The home is in Broughton, a residential area of Salford, close to local shops and within a bus ride of Salford’s shopping precinct. The current fees for Laburnum Court range from £364.41 to £514.25 per week. There are additional charges for individual services such as chiropody and hairdressing. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The key unannounced inspection site visit of Laburnum Court took place over one day. The site visit is part of the key inspection process. A key inspection looks all the key National Minimum Standards and sees what the home is doing to meet them. Other standards were also looked at. Before the site visit, and as part of the overall key inspection process, the home completed an Annual Quality Assurance Assessment (AQAA) which is a self-assessment that focuses on how well outcomes are being met by people who use the service. It is one of the main ways that we get information from providers about how they are meeting outcomes for people using their service. The AQAA is completed once a year by all providers, whatever their quality rating. The completed AQAA was returned to us on time and was very detailed. The home told us what they had done since the last inspection and what their intention was to improve services in the next 12 months. At this inspection an Expert by Experience (expert) was used. This means that an independent volunteer who has experience of receiving care and health services was used to provide a picture of the home and services from the viewpoint of the people living in the home. Comments from the report produced by the expert are, where appropriate, included within this report. During the site visit we also met with the continence advice nurse and the tissue viability nurse, both of whom told us about how the home supported people who use the service to achieve continence and, as far as possible, be free from pressure sores. The care of two people who use the service was cased tracked, this means the their care needs and services provided were looked at in depth. The term preferred by people living at Laburnum Court is people who use the service or service users. These terms are, therefore, used when referring to those living at the home. Survey forms were provided to people who use the service, their families and staff. Information received is, where relevant, included within the report. Comments received after the report is completed will be included in the next inspection process. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 6 Since the last inspection, which took place in March 2007, the CSCI has received a number of allegations and concerns regarding the care of people who use the service. The Local Authority has commenced safeguarding procedures and are investigating some of the issues of concern What the service does well:
The home provides nice accommodation for people who use the service. It is homely and well maintained. Decoration is personalised and specialist advice has been sought about how best to decorate the home to suit the needs of those who have dementia and associated conditions. People who use the service are treated as individuals, and there were many examples of how they were supported to maintain their individuality. Care plans were personalised and people had been involved in the making of their care package and signed to say they agreed with the support to be provided. Service users were observed to be able to chose their own style of dress which identified their individuality and wore clean, well maintained and pressed clothing. Their rooms were different in style and decoration, and they had been able to bring items from their own homes to make them as personal as they wished. People who use the service have their health care needs monitored and received support to, as far as possible, maintain good health. Meals and meals times are pleasant experiences, with service users being able to choose food options for themselves. The kitchen staff have knowledge of each service user and spend time getting to know their personal preferences. The expert told us “The lunch given to me was very enjoyable and there was plenty on the plate, it was well cooked and served up very well.” Service users told us they received care and attention in a timely manner. The expert told us that service users were able to call staff in the night and receive support when they required. Morning routines were to their liking, in that, they did not feel they were woken inappropriately. The expert told us that they had spoken to a number of service users, both men and women, covering how they felt about living at the home and they all seemed very happy there, with one service user saying “It was better than being at home”. After observing care practice and speaking with service users, the expert concluded, “the home was very pleasant and appeared well run”. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Though the home does provide some activities for service users, arrangements should be in place to provide daily opportunities for all service users to socialise or have companionship. This would help them to develop relationships and friendships and promote better mental health and wellbeing. The home should improve the way service users are offered alternative choices of meals when they do not wish the main meal served. It was observed that one service user did not wish to eat the main meal, saying, “I don’t fancy it” the meal offered was liver, mashed potatoes, cabbage and carrots. The carer offered an alternative of just mashed potatoes and gravy. The service user just ate the mashed potatoes. The practice of the staff means that it is quite possible one service user or more did not receive sufficient choice or nutrition when the main meal of the day was served. This continued practice may place service users at risk of weight loss and restricted choices. Staff also need to beware of service users’ needs, in that, their hearing may be reduced through the ageing process. One service user was observed watching the television, but the sound was so low they could not hear it. Staff seemed unaware that the volume should be louder, even though they were asked to turn it up. The home is open and honest in its recording systems, which means that they record all accidents happening in the home. As a consequence, a significant number have been noted. There is a system for monitoring accidents and looking for common features in an attempt to reduce accidents. Notwithstanding this, action should be taken to actively reduce accidents. Staff training is in place, but training records identified that some staff have an assortment of essential training outstanding. This could mean service users are being supported by staff who are not trained. Systems should be introduced to make sure staff receive training in a timely manner. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 8 At the time of the site visit, we had not received an application to register the manager of the home, even though she has been at the home in excess of 12 months. There was a requirement made about registration at the last inspection. Laburnum Court is being run without a manager who has successfully completed the registration process and found to be fit by us to run a care home. This could mean that people who use the service may be at increased risk of having their home managed by someone who is unsuitable. 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. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Standard 6 is not relevant to this service. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People who use the service have their needs assessed and are able to visit and receive information about the home prior to making any decisions about their future. EVIDENCE: Southern Cross Healthcare Services Ltd has written pre-admission policies and procedures in place which are followed by the home. Files looked at confirmed that the manager had visited prospective service users in their own homes and/or placement to assess their needs and provide them with information about the home. People who use the service told us that they had received enough information about the home. Furthermore, they are able to visit the home and look around, have a meal and view a room before making any decisions about their future.
Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 11 The manager recognises the importance of good pre-admission procedures and has made a commitment within the AQAA to develop the pre-admission and admission procedures for the benefit of prospective service users. Key workers are to be appointed and introduced in advance of service users’ admission to the home. The key worker is to have responsibility for initially supporting the service user to move in and become familiar with their surroundings. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. All service users have their care needs recognised, recorded and met. EVIDENCE: People who use the service have written care plans in place. Those looked at were up to date and relevant to the current needs of the service users. Service users have their individual needs assessed and risk assessments were also in place where there is an identified need. Health care records detailed when service users received medical attention and services from health care professionals. During the site visit we were able to talk with health care processionals about the conduct of the home and the support services in place. The health care professionals told us that the home is thorough when completing continence assessments and that all requests made by the continence nurse are met. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 13 Records are clear and the action taken to support service users’ continence can be seen. This means that continence advisors received enough information to make an accurate assessment of the service users’ needs and requirements. The tissue viability nurse told us the home works well at minimising pressure sores and that, currently, they are working on preventative measure to make sure, as far as possible, service users are free from pressure sores. Staff told us they receive and have access to service users’ care plans and are involved in completing records. One staff member told us about their responsibility as a key worker and said “As carers we fill up the daily information report every time we are on a shift. We do the weekly progress report for the residents that are assigned to us. We do the tidying up of their wardrobes and know what they need to improve the care given to them. People who use the service told us that they felt they had their care needs met and that there were always enough staff around to support them. People who use the service have access to the doctor and receive their medication as prescribed. Medication administration records were completed correctly and standards for administration were maintained. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People who use the service are able to maintain their individuality, daily routines and have control over their own lives. EVIDENCE: Care plans hade been developed to include service users’ personal preferences for their daily routines and social activities. During the site visit the expert spoke with people service users about their routines, they told us they did not have any complaints about how the staff got them up in the morning or how they were cared for in the night. They also told us that staff generally listened and acted on what they said. During the course of the site visit the expert observed one service user watching television with the volume on very low and staff were asked several times to increase the volume. The expert also noted that some service users experienced difficulty hearing what some staff were saying to them and making themselves understood.
Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 15 Staff should be trained and advised to speak clearly and appropriately to meet the individual needs of service users. Staff should take time to make sure they can be understood and that they themselves have understood what is being said to them by people who use the service. The home provides activities and has employed an activities co-ordinator, therefore when they are not on duty, activities are not always completed. A full activities programme should be developed to meet the needs and preferences of service users on both floors. At the time of the inspection the activities co-ordinator was on sick leave, this meant that the opportunity to join in activities was drastically reduced. Staff should be trained and designated to support people who use the service to have at least the daily opportunity to join in some activity and to socialise. This would promote conversation, positive relationship building and the wellbeing of people who use the service. Despite this, service users have been offered the opportunity to go to a safari park and other activities have taken place. Records maintained confirmed that one to one time is spent with some service users, who have their post read to them, and “pamper” sessions are enjoyed by those taking part. Ten of the 13 service user surveys stated they were satisfied with the social arrangements at the home. The AQAA identifies that there needs to be continuing development of activities and that the home is seeking advice and services to ensure the social needs of service users are met. The manager recognises the importance of meeting the complex needs of those with Alzheimer’s and associated conditions. The home has numerous tactile boards displayed that encourage people who use the service to touch and remember everyday items. Family and friends are encouraged to visit and are made to feel welcome. The visitors’ record is maintained appropriately to ensure fire safety regulations. The manager said that family and friends are encouraged to meet with her and each other and that an attempt to form a family committee is underway. Relatives’ meetings are held and, from information recorded, it could be seen that those who join in have given valued opinions on the services offered and have identified ways in which they could be further involved with the home. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 16 Meals and mealtimes are enjoyed by service users. The home has recently developed its menu to make sue service users’ favourite meals are included. Tables were laid with items such as teapots and milk jugs, which support some service users to serve themselves and others. One service user said that “sometimes they are just for show and not filled up”. It was noted that the menu for meals was on display in the entrance of the home and although it displayed the meals for a month, the printing was so tiny that we could not read it without difficulty. The menu has yet to be produced in a format suitable for people who use the service and advice is sought to consider picture menus for some people who use the service who have comprehension difficulties. This would support them to recognise food and assist them to make their own choices. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People who use the service are protected by adult protection procedures and are aware of and are able to make complaints and raise concerns. EVIDENCE: Southern Cross Healthcare Services Ltd has a written complaints procedure that is provided to people who use the service and their relatives. The manager makes sure that all complaints received are recorded and action taken to resolve them. People who use the service told us that they knew how to complain and that they had someone they trusted who they could talk to if they had any concerns. We have received a number of notifications from the home about significant and serious events that have taken place at the home, as well as information from other people. Since the last key inspection, three allegations of abuse and/or mis-conduct have been made. Appropriate safeguarding procedures have been put into place and have or are being investigated under Local Authority safeguarding procedures. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 18 Staff have been trained to identify and report suspicions of abuse and are aware of their responsibility under the protection of vulnerable adults and duty of care procedures. Each month the service manager visits the home to complete Regulation 26 visits, this means all aspects of the home are looked at and monitored, including the recording of complaints and occurrences. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People who use the service live in a homely, clean comfortable environment. EVIDENCE: Throughout the site visit all areas of the home were free from odours and generally clean and well presented. People who use the service have a number of areas they are able to use for seating during the day and evening. Lounges have recently been upgraded with redecoration and furnishing making the seating areas nice place to sit. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 20 Dining areas are personalised and pleasant places, which encourage service users to sit and chat with each other in comfort, whilst enjoying their meal. The cleanliness of one dining area needed improving. Kitchen units were not clean inside, dust and debris was evident on tiles, tile ledges and skirting boards; there was also debris in corners. Food in the kitchenettes was not dated when opened and use-by dates were not noted. Kitchen areas would also benefit from upgrading, as units were showing signs of general wear and tear and ageing. Bathing areas have been personalised, however practice for storing soiled clothing and continence products was not maintained in all areas. One room in particular had a odour and contained a soiled quilt which had not been sealed and stored correctly. Bedrooms were individual in their decoration, personalised, clean and well presented. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People who use the service receive support from staff who are appropriately recruited and trained. EVIDENCE: Inspection of staffing records confirmed that robust recruitment and selection procedures are followed. All staff had the required documentation in place, including application forms, references and statutory checks. Staff complete induction procedures and further complete an induction programme that meets the required standard set by Skills for Care. Staff told us that they received training suitable to their role and responsibilities, and that they are kept up to date with new ways of working. Since the last key inspection, 14 staff have left. New staff have been recruited to make sure staffing levels are maintained. Currently, 40 of staff are trained to National Vocational Level (NVQ) at level 2 or above, which means the home has not met its target of 50 of its workforce being trained in NVQ. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 22 Training and development records identified that whilst training was routinely provided, some staff had not received mandatory training and, for some, training was outstanding. The training matrix provided did not identify that that infection control training had been undertaken. Basic food hygiene was required for some staff, as was moving and handling, POVA and first aid. The rota of hours worked needs to be more descriptive in order to clearly identify how the home is staffed. Full names of staff should be used at all times, including bank staff. Staff spoke positively about working at the home, with one saying about the manager’s attempts to cover duties; however, at times, staff shortages are of some concern and cause difficulties in meeting the needs of service users as quickly as they wish. When asked what they thought the home did well, one staff said “Client care”. Throughout the site visit staff were observed to be attentive and supportive to people who use the service, providing assistance in a timely manner. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 23 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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users live in a home which is run for their benefit and which is managed well. EVIDENCE: The manager has been at the home for some time, and although she has completed NVQ 4 training and is currently undertaking the registered manager’s award, there has been no application submitted to commence the registration process for the manager. This was a requirement at the last key inspection. The manager said information had been sent to us but not received. The manager is to submit a new application to the North West Regional Registration Team as soon as possible.
Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 24 The manager has a strong direct leadership style and throughout the inspection the manager stated her commitment to developing services to meet the needs and preferences of people who use the service. When asked about the home and its management, staff were generally complimentary, they had the right amount of support and information provided to them and that the manager carries out unannounced spot checks on staff and their record keeping to see if standards are maintained correctly. People who use the service have been consulted about the services they receive, however Southern Cross Healthcare Services Ltd does not have systems in place to quality assess this information. This means there is no specific information about what people think the home does that is good or how they think it could be developed. Staff have commenced receiving supervision and annual appraisals and training and development files are being updated to make sure all staff’s identified needs are recognised and that they receive the support and training they require. Health and safety records were looked at. All accidents are recorded and information filed on the individual service user’s file. We are notified of all serious incidents, including accidents where injuries have or may have occurred. One accident is currently being investigated under the Local Authority’s safeguarding procedures. The manager stated that accidents are not uncommon at the home and an analysis of all accidents is undertaken. Service records for the home confirm information in the AQAA about annual servicing and checks of equipment. The home has recently achieved a five star rating following the inspection of the Environmental Health food safety department. Regulation 26 visits are completed. The records identified that small balances held for people who use the service are checked and full audit procedures are undertaken. The operations manager also evaluates accidents within the home and all health and safety matters. Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 25 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 X X 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x x 3 x 3 Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 26 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 OP31 Regulation 9 Requirement The manager must make application for registration with the Commission for Social Care Inspection. (Timescale of 20/5/07 not complied with). Timescale for action 15/11/07 Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 27 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 OP14 Good Practice Recommendations Arrangements should be in place to make sure service users have the opportunity to join in daily social activities and/or have social support to meet their individual preferences. Systems should be in place which make sure all staff offer service users an alternative meal choices when the main meal served is not wanted. Such meal choices should be of the same nutritional value. Cleaning routines should be improved within the dining and communal kitchen areas. Opened food stored in the communal kitchen areas should be appropriately dated when opened and have clear useby date in place, to make sure food is not served to service users which may be out of date. Where signs of wear and tear are evident in the communal kitchen areas, units and work surfaces should be replaced or upgraded. Consideration should be given to increasing the amount of work surfaces. Action should be taken to make sure toilets and bathing areas are maintained in a hygienic manner, including the management of soiled items. Systems should be in place to promote and support staff training in NVQ at level 2 or above. Mandatory and relevant training should be provided in a timely manner, including infection control, basic food hygiene, and moving and handling, etc. Service users, relatives, staff and relevant stake holders should be consulted as part of the home’s quality assurance procedure. An annual public report should be produced to detail the outcome of the audit and action taken by the home. Such reports should be submitted to us. 2 OP15 3 4 OP26 OP26 5 OP26 6 7 8 9 OP26 OP30 OP30 OP33 Laburnum Court DS0000006734.V348553.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Area Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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
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