Inspection on 22/02/07 for Lakeview

This inspection was carried out on 22nd February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lakeview 17/10/07

Lakeview 22/05/06

Lakeview 02/02/06

Lakeview 08/08/05

Lakeview 01/03/05

Lakeview 13/09/04

Lakeview 08/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Lakeview Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA Lead Inspector Mrs Joanna Wooller Key Unannounced Inspection 22 February 2007 09:15 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 DS0000022331.V331230.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. DS0000022331.V331230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lakeview Address Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA 01922 409898 01922 403434 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) alphacarehomes.com Alpha Health Care Limited Mrs Christine Armstrong Care Home 151 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (53), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (10), Old age, not falling within any other category (25), Physical disability (123), Physical disability over 65 years of age (123) DS0000022331.V331230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Physical Disability (PD) minimum age 60 years on admission Physical Disability (PD) minimum age 49 years on admission - 2 persons 1 DE - Named Resident minimum age 59 years on admission To provide a maximum of three day care places. Date of last inspection 22 May 2006 Brief Description of the Service: Lakeview Care Home with Nursing, forms part of the Lakeside Site. The home is owned by Ralton Care Homes Ltd, Alpha Care Homes Ltd and was purpose-built during 1996/97. Lakeview is set within its own landscaped gardens and grounds amounting to over 5 acres. It is situated on the main A34 trunk road midway between Walsall and Cannock with a regular bus service stopping directly outside the home. Birmingham, Stafford, Wolverhampton, Lichfield and Brownhills are all within 20-30 minutes drive by car. The services offered by the home are: - Dementia, Mental disorder (excluding learning disability or dementia), Old age (not falling within any other category), Physical disability, Physical disability over 65 years of age. Lakeview has 151 beds and is divided on two floors served by three passenger lifts. Service users are accommodated in single rooms with en-suite facilities. There are a limited number of double/shared rooms, which would be ideal for married couples. The nursing and personal care areas are divided into separate corridors each with its own Head of care, team of nurses and care staff. The units were recently renamed to represent one of the lakes in the Lake District. These units are named as Windermere a 38-bedded residential Unit, Grassmere a 35bedded nursing unit and Buttermere a 25-bedded nursing unit. The 53-bedded mental health unit is located on the second floor and this is now divided into two units 32-bedded unit Ullswater and 21-bedded Loweswater. Fees - £ 309 to £ 550 DS0000022331.V331230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day by the lead inspector and two co-workers. The management at the home assisted the inspectors throughout the day. The inspection included the following elements; A tour of the building, Observation and inspection of records relating to provision of care, Discussions with several service users, Discussions with all the staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues and health & safety. Feedback from Service Users and relatives was positive. They praised the staff for the care they gave to the individuals. What the service does well: What has improved since the last inspection? The manager is now registered with the Commission For Social Care Inspection. DS0000022331.V331230.R01.S.doc Version 5.2 Page 6 No complaints have been received by the Commission For Social Care Inspection or reports of any vulnerable adult situations. The care documentation at the home has improved but there is still some room for more improvement in some areas. Better interaction between staff and Service Users was evidenced but further input was identified as being required. 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. DS0000022331.V331230.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 DS0000022331.V331230.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are individually assessed prior to admission, which ensures that their needs can be met whilst at the home. EVIDENCE: The manager prior to admission individually assesses each Service User. Clear notes were recorded and an admission is only organised once the home can ensure that the Service Users needs can be met. This is agreed in writing. Potential Service Users and their representatives have the opportunity to visit the home, read the Statement of Purpose and look around the home with a chance to speak to other Service Users and the management. One relative spoken to confirmed that they had been included in this procedure and had found the staff most helpful and reassuring. DS0000022331.V331230.R01.S.doc Version 5.2 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service Users health, personal and social care needs are set out in care plans to ensure their needs can be met. The documentation seen at the visit was not completed fully and required further input from the named nurses and the Service User or their representative to meet the standard fully. Service Users are treated with respect and their privacy respected, however further efforts were noted to be required with some staffs’ interaction with service Users especially when hoisting or assisting with their independence. Service Users are assured that at the time of their death, staff will be respectful to them and their relatives. EVIDENCE: The inspector spoke to several Service Users during the visit and they spoke highly of the staff and the care they received. The Service Users care plans and associated documentation was generally well written and most reflected the current condition of Service Users. Some DS0000022331.V331230.R01.S.doc Version 5.2 Page 10 assessments as identified to the manager were out of date and must be updated annually to be meaningful. The documentation seen enabled the inspector to evidence that health and personal care needs were being identified and in most cases addressed by the nursing staff. The documentation was found to be in a period of change and this was causing some confusion relating to assessments and the ability to evidence the Service Users current condition. The local GP’s practice supports the home and reviews their individual patients. Medication administration was inspected and on one unit it was identified that medication had not been signed for on several occasions. There was no explanation available as to why this had happened. A comprehensive medicines policy is in the home along with the NMC guidelines and a requirement was made to ensure that trained nurses adhere to this. One relative spoke of the “excellent care that the staff had delivered to her mother and she was pleased with the choice they had made regarding the home”. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. Privacy and dignity were being afforded to Service Users, and the inspector evidenced some good interaction between staff and Service Users in some areas. Care staff were able to demonstrate privacy issues being addressed by the inspector evidencing care staff knocking on doors before entering bedrooms. DS0000022331.V331230.R01.S.doc Version 5.2 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was providing most of the residents with a lifestyle that met their needs. They were provided with a range of social activities, a good standard of meals and were supported to make choices over their lifestyle. Although the home has made progress there was still a way to go to ensure that all the residents in the EMI units were provided with a lifestyle that met their needs. EVIDENCE: Time was spent in all units talking with staff and Service Users. Within the EMI units (Ullswater and Lowswater) Service Users were observed both in the lounge and during lunchtime. A sample of documentation was looked at in every unit. Discussions also took place with the activity staff. The home in the majority of instances was putting together an individual life map that identified important aspects about a person’s life including previous occupation, interests and important contacts and relationships. In a few instances there was a comprehensive social history on file. Progress had been made in developing social care plans but on many of these the information provided by the life map was not included. Discussions with the activity staff DS0000022331.V331230.R01.S.doc Version 5.2 Page 12 confirmed them to be well motivated and aware of those residents that liked to join in with organised activities. The staff on the EMI unit had received some training and had literature to help them identify appropriate activities for Service Users with dementia care needs. All units had a schedule of events on their notice board. The activity staff were working hard to provide a good range of activities within the units. These included skittles, bingo, darts, dominoes, baking and quizzes. In addition the home arranged for entertainers to visit the home and recently there had been trips out shopping and to a garden centre. On the day of the inspection a large group of Service Users were playing darts in one unit (Grassmere), and Service Users in another unit (Windermere) were playing skittles. There was a lively atmosphere within these units and those individuals involved were clearly enjoying themselves. A number of residents on the EMI unit had been doing some craftwork making cards and last week they had made Valentine cards. For those unable or not wishing to take part in group activities the activity staff do provide some one to one support. Service Users also have the opportunity to have their hair done weekly. The home offers a Church of England service. Whilst the activity staff provided stimulation within the EMI units there was a need for some of care staff to also see their role as providing activities such as social and emotional support and promoting independence in addition to attending to residents’ physical care needs. Some staff were working positively with Service Users. They regularly interacted both verbally and through touch and showed sensitivity and understanding. However there were others that needed to develop these skills and attitude. Observation showed that when some Service Users were distressed and shouting some staff did not respond. Also some staff did not often interact with Service Users. Several times care staff were observed in a lounge supervising but did not interact with the individuals. In addition two staff were hoisting and toileting a Service User and there was no explanation given to him until the Care Manager intervened. Two staff spoken to was not aware of individual’s social history and did not understanding why a person may be unsettled. On the EMI unit care practices need to be more person centred in order to be able to work more effectively with individual Service Users. They should develop individual communication plans as relationships are based on communication and in working with people with dementia this is a vital area in understanding people and their needs. The home could also look at developing life history books to help staff to have a better understanding of the residents. Discussions with Service Users and staff and observation showed that the home’s routines were relaxed. Service Users could get up and retire when they wanted. They could choose whether to join in with activities and whether to have meals in the dining room or in their bedroom. Comments included ‘I go to bed when I like’ and ‘ I don’t want to go into the lounge so I watch the television in my room’ and ‘I choose to have my meals in my room’. DS0000022331.V331230.R01.S.doc Version 5.2 Page 13 The home encouraged relatives to visit and during the inspection there were a number of visitors in the home. Several relatives visited daily and were involved in providing care for their relative. One lady spoken to stated that relatives visited regularly and they were able to bring her dog in to see her, which gave her a lot of pleasure. A relative spoken to said that the home always contacted them to keep them informed of any issues relating to their relative. The home also encouraged residents to go out with relatives and organised some trips for those that are able for example to the pub, the theatre and shopping. The home also has a number of outside entertainers visiting the home. Service Users liked the home’s meals. Comments included ‘the food is fine. You get a choice’. Another lady commented ‘Very good food. The meat is always tender’. Service Users were provided with choice at all meals. The care staff spoke to individuals about the meals and explained what the choices were. There was a cooked breakfast twice a week although if residents requested they could have a cooked breakfast every day. At lunch there was a main meal on offer- on the day of the inspection it was hot pot – and a range of alternatives including salad, omelette, baked potato and sandwiches. If requested the chef will try to accommodate any wishes. The home offered a hot pudding but there was also yoghurts and ice cream. There was a lighter meal at teatime something on toast as well as soup and sandwiches and cakes. The home provided residents with supper of sandwiches or biscuits of they wanted it. Drinks, toast and biscuits were available from the staff throughout the night. Fruit was available in the units. The home was providing for any specific dietary needs including diabetes, low fat and for individuals that required soft or pureed diets. The home provided suitable equipment to promote independence including plates with lips on and the use of appropriate cutlery. Observation with the EMI unit showed an improvement in the feeding of Service Users since the last inspection. Observation of lunchtime in Ullswater showed Service Users to be supported in an appropriate manner with dignity and sensitivity. Whilst the home had made progress in respect of ensuring residents in the EMI units were fed correctly there were still instances where meals were becoming cold when staff were feeding other residents. All Service Users had a nutritional assessment that was reviewed monthly. Weight was checked monthly. DS0000022331.V331230.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good Service Users are confident that their complaints and concerns will be listened to and action taken. Service Users are protected from abuse. EVIDENCE: As at the previous inspections an examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and service users, evidenced that complaints were listened to and continue to be dealt with in the correct manner. No complaints, incidents of neglect or abuse of any kind have been reported to the Commission For Social Care Inspection. Staff training and observations of service users ensured that they are protected from all forms of abuse. A number of thank you cards from service users relatives were on display. One relative said she would be able to talk to the Manager before making any type of complaint and felt that it would not be an issue. DS0000022331.V331230.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24, 25 and 26 Quality in this outcome area is poor This judgement has been made after a sample tour of the home. There were a number of areas that required attention to their decoration and refurbishment of carpets. Service users were at risk without the equipment to summon for assistance. EVIDENCE: Windermere: - This ground floor unit had a heater in a bedroom not secured to the floor and a possible hazard for the resident. Bathroom G2 has broken tiles, which were sharp to the touch. Both of these issues were addressed on the spot by the handyperson following contact by the Deputy Care Manager who escorted the inspector. Grassmere: - This unit had a number of carpets not acceptable to the hygiene and quality expected. In particular the lounge referred to as Arthur. It was DS0000022331.V331230.R01.S.doc Version 5.2 Page 16 identified that one of the recliner chairs was broken and a potential hazard to service users health and safety. A minimum of three bedrooms was without a call system; the deputy care manager was unable to validate the reason for this. Each of the service users should have the means to summon for assistance. The water temperatures in bathrooms G5 & G6 were below the required safe temperatures. On the corridor near the laundry a fire door had been negated by the removal of one part of the magnetic fixture, this door can now not be held open. The fire officer had not agreed the digital lock, as it was not wired into the system. The inspector was told that the door was to be refitted with a digital lock appropriately wired. Buttermere: - It was identified that King George lounge had an extremely poor quality carpet, which was stained. Within this lounge were another chair that was broken and a stool to hold up the foot. This was a potential hazard for Service Users health & safety. The decoration in a number of areas was aged, marked and stained; the need for on going re-decoration was required. Within bathroom F7 the bath hoist had a part broken and the toilet seat was exceedingly loose and a potential hazard to users. The water temperature was below the required temperature. The bath taps in the main bathroom were with out a section to turn the shower section on easily. Ullswater: - within one of the bathrooms there was no water this has been like this for two weeks. The seal around one part had to be sent for. The bath was chipped near to the hoist, which had a split handle, tiles were broken and a potential hazard to any person entering the room. Carpets in this unit would benefit from replacing in particular F15. In general the carpets in corridors were in need or replacement. There should be a monthly audit of the furnishings to ensure, safety and suitability for use. There should be a monthly audit of the service users call system to ensure they were available at all times. The first floor decoration had lifted some of the individual units and highlighted the need for more decorating in other parts of the home. A sample of the bedrooms during a tour of the home identified that numerous personal possessions had been brought into the home. DS0000022331.V331230.R01.S.doc Version 5.2 Page 17 The inspectors identified that possibly the nicest lounge on the EMI unit was not being used and it was suggested that consideration should be made to use this lounge whilst the front lounge is being upgraded. DS0000022331.V331230.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. This judgement has been made from evidencing records and from discussions with the management. There was a need to review the staff records to ensure all aspects were current to protect the residents. EVIDENCE: The homes rosters were examined. The home was providing adequate staffing levels to meet the individuals’ needs. This included providing additional staffing at busy times such as in the morning and at lunchtime to assist Service Users to eat their meals. The staffing levels were based on the numbers of Service Users and their level of dependency. All the nursing units had a trained nurse on duty. The staffing on the EMI units was at a greater level than on the general nursing units having a qualified nurse on each unit throughout the day and nine care staff on the morning shift and seven on the afternoon shift. Although staff worked on a specific unit there was some movement of both Service Users and staff between the units depending on specific needs. DS0000022331.V331230.R01.S.doc Version 5.2 Page 19 In addition to the care staff at the home there were activity staff attached to each unit. The home also provided sufficient domestic, catering and maintenance staff. The inspectors were provided with a selection of staff records including the trained nursing staff. Criminal Record Checks, references, staff training records were evidenced. In general they were evidenced to be adequate, a minimum of sections were incomplete. There is a requirement for the records to be reviewed to ensure that all the records had a current photograph, and copy of a birth certificate. The matrix and records evidenced that obligatory training with the exception of First Aid training was current. The home had invested a lot of time and expense into training. It was identified that in Windermere there would be no member of staff on duty at night with First Aid training. To expect another member of staff to attend would leave others at risk. DS0000022331.V331230.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This judgement has been made using the available records and speaking to the person responsible for finances. The last fire drill was September 2006 a further one is overdue, this may put service users at risk if staff were not currently up to date with procedures and practices EVIDENCE: From observations made by the inspectors, the discussions with service users and one relative, and discussions with the manager and staff, it was evident that the home was now being run in the interests of service users. Relatives spoke positively of the Management at the home and felt that the Manager was approachable. DS0000022331.V331230.R01.S.doc Version 5.2 Page 21 The Inspector checked all relevant records required meeting the National Minimum Standards, these included fire records, electrical testing, hoist servicing and testing, accident records and staff training relating to food hygiene, moving and handling and fire training. A discussion with both Service Users and representatives evidenced that all service users had the opportunity to handle their own finances and all Service Users and their families had chosen to do so. The home had robust detailed systems in planes that cross-referenced the transfer, receipt and expenditure of Service Users personal finances. A sample of finances were checked and found accurate. The home had a system in place to obtain feedback from service users, the manager provided records of meetings with the homes main general practitioner. The report did not give feed back on the service provided. Service users surveys were taken in January 2007 these documents have been forwarded to head office. Records evidenced service users meetings in each of the units with staff. The records for the prevention and testing of the fire system was current; with the exception of the fire drills, from the records it was not possible to ascertain if all the staff had been involved in a fire drill. The last drill was recorded on the 1 September 2006. Records did not evidence the times the drills were instigated. It was recommended that staff sign personally, the times drills were activated and time they take to complete the drill. DS0000022331.V331230.R01.S.doc Version 5.2 Page 22 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 1 1 X X 2 2 1 1 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000022331.V331230.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 OP12 Regulation 12(5)(b) & 18(I) Requirement Timescale for action 22/03/07 2. OP38 23 (4)(e) The registered person must ensure that all staff on the EMI Unit is made aware of the importance of providing stimulation, positive interaction and sensitive approach to Service Users with dementia care needs. The registered person shall 22/03/07 ensure by the means of fire drills and practices at suitable intervals each member of the staff including night staff were part of a fire drill. The registered person shall ensure that unnecessary risks to the health and safety are identified and as far as possible eliminated. All the services users should have access to a call system at all times. The registered person must ensure that the medication administration is in line with the NMC and the homes medication policy and procedure. Some medication was unsigned for. 22/03/07 3. OP25 13 (c) 5. OP9 13 (2) 22/03/07 DS0000022331.V331230.R01.S.doc Version 5.2 Page 24 6. OP29 Schedule 2 The registered person shall ensure that all the required elements required in Schedule 2 were current on the staff files. 22/03/07 7. OP38 4 (a) The registered person shall take 28/02/07 adequate precautions against the risk of fire including the provision of suitable fire equipment. The fire door referred to in this report should be brought into working order as soon as possible. The registered person shall ensure that the equipment used at the care home is maintained in good working order. The registered person shall having regard to number and needs of the service users ensure that all parts of the home are kept clean and reasonable decorated. The registered person shall ensure that the home have procedures in place to ensure that meals are kept warm for residents in the EMI unit. 22/03/07 8 OP19 23(c) (d) 9 OP15 16 (2i) 22/03/07 10 OP7 15 (2b) 11 OP8 15 (2c) The registered person shall 22/03/07 ensure that all care records are current up to date and demonstrate ongoing review of an individual’s condition. The transferring of information to new care documentation must be meaningful and correct. 22/03/07 The registered person shall ensure that Service Users records are reviewed by the individual or a representative as appropriate to agree the care plan and discuss any changes in the care delivered. Also the Service Users or a representative DS0000022331.V331230.R01.S.doc Version 5.2 Page 25 12 OP20 23 (2c) 13 OP26 16 (2j) 14 OP23 2(j) must sign assessments. The registered person shall 22/03/07 ensure that an audit of furniture in the home is completed to ensure that it is suitable, safe and in good repair at all times. The registered person shall 22/03/07 ensure that satisfactory standards of hygiene are maintained in the care home. The registered person shall 22/03/07 ensure that all areas of the home have a suitable water supply and water temperatures are satisfactory. 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 OP12 Good Practice Recommendations To look at ways of developing the person centred approach for residents with dementia care for example introducing of life storybooks and memory boxes. To develop the environment to aid residents with dementia care needs to maximise independence and minimise confusion for example pictorial signs and use of colour to help with orientation. To further record the time of day/night and time taken to execute the drill. For the staff to sign personally when they are involved in a drill. To commence monthly checks on the Service Users call system to monitor its effectiveness and that it is in working order 2. OP24 3. OP38 4. OP22 DS0000022331.V331230.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000022331.V331230.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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