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Inspection on 02/10/07 for Landemere Residential Care Home

Also see our care home review for Landemere Residential Care Home for more information

This inspection was carried out on 2nd October 2007.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Registered Providers had provided a statement of purpose and Residents Guide to the Home, and all new Residents applying to the Home would be appropriately assessed by the Manager before an admission was arranged. The Manager and staff were found to be attentive and supportive of the Residents, and completed a satisfactory level of administration to support this level of care. The Residents spoken with also said how helpful staff were to them, which was observed during this visit to the Home. Residents were found to be very well protected by the Complaints procedure and the Safeguarding Adults procedure in the Home. The Home was found to be well maintained throughout. All of the administrative arrangements to ensure that the Home met the standards set by law were found to be in place.

What has improved since the last inspection?

Since the last inspection, in January 2007, the Registered Providers and Manager have addressed the following items: The Manager has ensured that all Residents are provided with a copy of the Residents Guide. An appropriate large print copy of the Complaints Procedure is now provided to those Residents who have sight difficulties.Care plans are now reviewed on more frequent occasions to ensure they are kept up to date with Residents changing needs. When new staff are employed satisfactory details are now being obtained.

What the care home could do better:

The Residents Guide needed to be improved to ensure it contained information about the physical environmental Standards met by the Home. The Manager needed to update the care plans of all Residents to come into line with the new care plan and file format recently introduced into the Home. The plans of care also needed additional items addressing to ensure they met appropriate standards. There was also a number of issues that needed improvement in the record of medication kept by the Home. The work begun by the Manager to recruit a new Activities Coordinator needed to be completed to improve the activities provided for Residents. The amount of staff provided in the Home needed to be reviewed by the Registered Providers to ensure it was at least in line with that recommended by the Residential Forum. The Registered Providers needed to ensure that at least 50% of all care staff held a qualification of NVQ level 2 in Care (or equivalent). The supervision requirements of care staff also needed to be entirely put into practice. Mandatory training in Moving and Handling and Food Hygiene was required by a large number of staff.

CARE HOMES FOR OLDER PEOPLE Landemere Residential Care Home Inverary Close Off Grampian Way Sinfin Derby Derbyshire DE24 3JX Lead Inspector Steve Smith Unannounced Inspection 2nd October 2007 11:05 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 Landemere Residential Care Home DS0000001991.V348261.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. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Landemere Residential Care Home Address Inverary Close Off Grampian Way Sinfin Derby Derbyshire DE24 3JX 01332 272007 01332 271224 maxine.smith@anchor.org.uk sharon.blackwell@anchor.org.uk Anchor Trust 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) Ms Maxine Elizabeth Smith Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: Landemere is a purpose built care home for Older People, was built in 1991, and provides accommodation for up to 40 Older People. It is situated close to local amenities and to bus routes serving Derby city centre. The accommodation is on two floors, with access to the first floor via staircases or via a shaft lift. All rooms are single occupancy, with en-suite facilities. Each room has the benefit of refreshment facilities and is fitted with a small refrigerator. Services include personal laundry, meals, and personal care designed to meet individual needs. The charges made for a room at Landemere Care Home range from £325.00 a week to £384.00 a week, dependent on the bedroom provided and the needs of the particular Resident. A copy of the Commission’s inspection report is available from within the Home. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period 7 hours. Discussion was held with two Residents, and the records of four Residents were ‘case tracked’. Discussion was also held with one of the Manager and with one member of the care staff. A number of records were examined, and the bedrooms of the four Residents whose records were case tracked were examined, together with all public areas of the Home. The Commission’s Annual Quality Assurance Assessment questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, but only 2 were returned at the time of this inspection. They both commented most favourably on the Home. What the service does well: What has improved since the last inspection? Since the last inspection, in January 2007, the Registered Providers and Manager have addressed the following items: The Manager has ensured that all Residents are provided with a copy of the Residents Guide. An appropriate large print copy of the Complaints Procedure is now provided to those Residents who have sight difficulties. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 6 Care plans are now reviewed on more frequent occasions to ensure they are kept up to date with Residents changing needs. When new staff are employed satisfactory details are now being obtained. 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. The summary of this inspection report can be made available in other formats on request. Landemere Residential Care Home DS0000001991.V348261.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 Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a statement of purpose for the Home together with a Residents Guide. However, although the statement of purpose contained information on the physical environment issues met or not met by the Home, the Residents Guide did not. Aside from this the Residents Guide contained all other required information, including information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. The records of four Residents were examined during this visit to the Home and a complete copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 9 When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being met, as demonstrated within care plans, although the administration of medication my well effect Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. Almost all of the basic information concerning each Resident was found to be in the files examined. That was, their name and date of birth, their next of kin, their GP, Care Manager and their date of entry to the Home. However, none of the files contained the preferred names of the Residents. Records of the Manager’s (mostly previous Managers) initial assessment of each Resident were not obviously found in three of the files. The Home had recently started to significantly alter its recording pattern and Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 11 the fourth file was such a file. This file did contain the Manager’s initial assessment of the Resident. It also contained the Manager’s Individual Plan of care which was also well completed. The other three files did have records of the needs of the Residents, but this was very hard to access, as they were written in the style of the Residents stating their needs. As a result staff would find it difficult to access the needs of these three Residents. Records of risk assessments were available in all the files reviewed. None of the Residents files reviewed contained appropriate records for those Residents suffering with dementia, concerning the Resident’s possible limitations of choice, freedom and decision making ability. The files showed that records of events affecting each Resident were kept by the Home, and staff were expected to complete each record at the end of each of the three daily shifts. The Manager had also started to share the ‘formal reviewing’ of Residents care needs, with the Social Services Dept, and between the two a 6 monthly review of each Resident was carried out, to which the Resident and their relatives were invited. All of the files were easy to read and satisfactory entries had been made by the care staff. The Manager said that she reviewed the records of each Resident at regular intervals, but she had not signed the records to indicate that this had taken place. The files were well organised, with different sections, although no confidential records were maintained in any of the files reviewed. All of the files contained a lot of detail of Residents past lives, which was very positive to see. All files also contained an Emergency Evacuation Plan for each Resident, should the Home be struck by fire or other disaster. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined, and a satisfactory system was found to be in use. However, the following issues needed to be addressed: A number of Medication Administration Record (MAR) sheets reviewed stated that ‘1 or 2’ medications could be given, but the record of medication given did not say whether 1 or 2 medication were actually given. When the MAR sheet stated that a medication must be given 4 times a day this must be provided. On at least one MAR sheet reviewed the medication was only given three times a day. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 12 A number of signature gaps were found on some of the MAR sheets reviewed. When creams were to be applied, this task was handed to care staff to carry out in Residents bedrooms. However, no record was maintained on the MAR sheet to say that this had been appropriately carried out. Gaps were found on the MAR sheet when Residents refused to take a medication, rather than the designated letter ‘A’. A number of Residents were administering all, or some, of their own medication, but this was not indicated on the MAR sheet. Discussion was held with Residents about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘Staff usually provide what I say I need, so staff listen to my views.’ - ‘Staff are very kind and always ask how I want things done.’ Discussion was also held with Staff, and very positive ways were described of assisting Residents within the Home. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Residents were asked about the activities provided in the Home. Those spoken with said that apart from bingo and occasional entertainers, little else was provided. Staff were asked about this and they confirmed that only the activities already listed were provided, with the addition of coffee mornings. The Manager also confirmed that this was all the activities that were provided. She also said that she was in the process of recruiting an Activities Coordinator to improve the activities provided by the Home. Residents said that they decided when they got up and went to bed – ‘Yes, I can get up and go to bed when I want.’ Another Resident said ‘I have one bath a week, and I am happy with that.’ Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘Yes, my brother comes into my room, and so I can Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 14 always see him in private.’ ‘I always see my family in private.’ A member of staff said that visitors could call at any time of the day and confirmed that Residents could always see them in private. Residents were able to say that the Home provided good meals and that a choice was available at breakfast, dinnertime and teatime meals – ‘A choice is provided at all meals, from two options, and the choice is always made at the dinner table.’ The Residents spoken with said that on occasions the choice of one of the meals runs out and so Residents have to have the alternative. Staff also confirmed this. The staff said that drinks and snacks were always provided between meals for Residents, which was witnessed during this visit to the Home, and that mealtimes were never rushed. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Providers or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: Residents said that if they had a complaint to make they would tell the Manager but they had not had to do this to date. The Commission had not received any notice of complaint since the last visit to the Home, in January 2007. Since that visit, the Manager had recorded a number of verbal concerns raised by Residents. These were reviewed and were found to have been satisfactorily dealt with. Good procedures were seen for both written and verbal complaints. The Registered Provider’s complaints procedure detailed that all complaints would be responded to by the Registered Providers or Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Manager said that a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ were available in the Home. The Manager also confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 16 taken would be recorded. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Manager said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were held. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was very well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and included the four bedrooms of the Residents whose care was reviewed at the time of this visit. The Home was attractively decorated throughout, and the lounge and dining rooms were most pleasant to sit in, and were provided with appropriate items for the Residents. The bedrooms seen provided very good space and provision for each Resident. All bedrooms were also provided with their own toilet. The Registered Providers had provided appropriate furnishings in all locations seen during this visit. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 18 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27, 28, 29 & 30. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Appropriate recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. However, staffing levels may result in Residents needs not always being appropriately met. EVIDENCE: The amount of staffing provided by the Home was found to be under that recommended by the Residential Forum for the three weeks examined; the 10 September to 30 September 2007. At the time of this visit to the Home it was found that under 50 of care staff had a qualification of at least NVQ level 2 in Care: only 41 . The Manager said that encouragement was being provided to staff to ensure that more than 50 of staff held the qualification as soon as possible. The records of two new staff employed during the past 6 months were examined to see whether the Manager had obtained all relevant information about them, and it was found that all information had been obtained. The Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year, and a member of the care staff also confirmed this. Landemere Residential Care Home DS0000001991.V348261.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Effective management arrangements at the Home were in place to ensure that Residents care was maintained at a positive standard. EVIDENCE: The Manager was in the process of obtaining her qualification of an NVQ level 4 in Management and Care. She said that she anticipated finishing the course by April 2008. The records of the monthly ‘inspections’ of the Home, carried out by a senior manager, were examined and found to be in good order. The Manager was able to show the annual development plan for the Home that reflected the aims and outcomes for Residents. She was also able to show the results of Residents surveys, and the results of relative surveys, both of which were posted on the Home’s notice board. These were reviewed and were Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 21 found to contain both positive and negative comments by Residents and their relatives. The negative comments were indicated as matters that needed attention, and the record showed how the Manager intended to address the negative comments with the expectation that they would be resolved. Staff were asked about the regularity of supervision in the Home, and the staff said that this was not provided, which was later confirmed by the Manager. However, the Manager added that some supervisions had been done, but as yet this was not a consistent approach by her and her senior staff. The training required by the Regulations was examined. This showed that Fire Safety training, First Aid training, First Aider training for senior staff and Infection Control training were all up to date. However, at least 50 of staff required training in Moving and Handling and in Food Hygiene training. This training requirement was also confirmed by staff spoken with. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that the Registered Providers had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. She also showed that a written statement of the policy, organisation and arrangements for maintaining those safe working practices was also in place. Finally, the Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Landemere Residential Care Home DS0000001991.V348261.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 14(1)(a) & (b) and 15(1) Requirement Residents individual plans of care must be up dated to the new style recently introduced to the Home, to provide easily accessed information on the needs of each Resident. The Manager needs to ensure that each Resident suffering with dementia, or their representative, has had the opportunity to discuss their rights of choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, as they deteriorate, at least on a 6 monthly basis. When the Medication Administration Record (MAR) sheets state that 1 or 2 medications can be given, staff must record whether 1 or 2 medication were actually given. The instruction provided on the MAR sheet must always be followed. If the MAR sheet says a medication must be given 4 Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 24 Timescale for action 31/12/07 2. OP7 17 & Sch 3, 3(q) 27/11/07 3 OP9 13(2) 27/11/07 times a day this must be adhered to unless a GP had altered the medication. Signature gaps on the MAR sheet must be followed up by the Manager. She should indicate on the back of the relevant MAR sheet why the gap occurred and her action when following this up. When creams are prescribed for Residents, the MAR sheets must be completed each time the creams are applied to Residents. When Residents refuse to take a medication the letter ‘A’ must placed on the MAR sheet in the relevant location. When a Resident is administering their own medication, the MAR sheet must record that the medication has been handed to the Residents to administer. 4. OP12 16(2)(m) (n) Activities both within and outside the Home must be further developed with resident involvement, to ensure the activities meets the needs, expectations and preferences of the residents. (This issue is outstanding from the inspection report dated 6 September 2006) Supervision must be provided for all care staff. Mandatory training must be provide for the 50 of staff requiring Moving and Handling training and Food Hygiene training. 31/12/07 5. 6. OP36 OP38 18(2)(a) 18(1)(c) (i) 27/11/07 31/01/08 Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The Residents Guide should contain a summary of the information held in the statement of purpose on the physical environment standards met/not met by the Home. The basic information held on each Resident should contain the preferred name of each Resident. When the Manager has reviewed a Resident’s file, she could indicate that this has been done by signing the record with a green pen. Each Resident’s file should contain a ‘confidential’ section. This section should be used for records made by staff that the Resident should not see and for information passed to the Home by professionals to which the Resident had not been made party. 2. OP7 3 4. OP27 OP28 Staffing should be improved to a level at least equal to that recommended by the Residential Forum. A minimum ratio of 50 of staff should be trained to NVQ Level 2 in Care (or equivalent). (This issue is outstanding from the inspection report dated 6 September 2006) The Manager should arrange for all care staff to receive supervision at least 6 times a year; once every 2 months. 5. OP36 Landemere Residential Care Home DS0000001991.V348261.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Landemere Residential Care Home DS0000001991.V348261.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. 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