CARE HOMES FOR OLDER PEOPLE
Langholme Arwenack Avenue Falmouth Cornwall TR11 3JP Lead Inspector
Paul Freeman Unannounced Inspection 3rd November 2006 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 Langholme DS0000009108.V318238.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. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Langholme Address Arwenack Avenue Falmouth Cornwall TR11 3JP 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) 01326 314512 01326 317577 home.fal@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Patricia Ann Bagley Care Home 39 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33) of places Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th May 2006 Brief Description of the Service: Langholme Residential Home is registered to provide accommodation and care for a maximum of 39 service users. The home is purpose built and provides accommodation on two floors. There is a large lounge on the first floor and dining room on the ground floor. The home is suitable for a resident who requires a wheelchair, and two lifts provide access to the first floor. Attractive garden are located at the rear of the home which are also wheelchair accessible. The home and grounds are maintained to a reasonable standard. Langholme is situated a short walking distance from the town centre of Falmouth and the Maritime Museum. All the facilities the town has to offer are within easy reach of the Home. Car parking is available for visitors to the home. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place on 3 November 2006 and 7 November 2006. This report focuses upon the areas of non-compliance that were identified at the last inspection and should be read in conjunction with report of the previous inspection that took place on 18th and 19th May 2006. Therefore the purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the inspection on 18th and 19th May 2006. Some of the key standards that were considered include assessment and care planning, health and safety and staff recruitment. The registered manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. The registered providers have also recently completed an audit of the services and facilities provided. The conclusions of this assessment have been taken into account. This is the second key inspection in this inspection year. This took place because a number of areas of non-compliance were identified at the key inspection on 18th and 19th May 2006. The providers have taken positive steps to address the shortfalls, which has had a positive effect upon the service and facilities provided. There continue to be areas where further improvement is required to make sure that residents are safeguarded. If the current rate of improvement is sustained a good quality service that safeguards residents and reflects their individual needs will be in place at the next key inspection. What the service does well:
Each resident has a care plan that summarises their needs and the care and support required. The plans are also regularly reviewed to make sure they accurately reflect the residents’ needs, preferences and choices. The Providers have established satisfactory arrangements to deal with any complaints or concerns raised by residents or their representatives or relatives. The evidence indicates that complaints are dealt with promptly and efficiently and wherever possible a satisfactory resolution is reached. Residents said there were no barriers to raising any issues with the management and staff of the home and were confidant that any matters would be dealt with in a satisfactory manner.
Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 6 Appropriate arrangements are also in place to protect residents from abuse and any concerns are reported to the statutory authorities for investigation. Residents are satisfied with standard of the environment and the facilities provided. The home is decorated and maintained to a reasonable standard and presents as welcoming and homely. Residents stated they were pleased with their bedrooms and the majority of rooms have been personalised by the occupants. A number of bedrooms have also recently been redecorated. Some of the bedrooms also have en-suite facilities and a number of communal bathrooms and toilets are distributed throughout the care home. These facilities are within a reasonable distance from communal areas and residents bedrooms. Specialist disability equipment is available to residents throughout the home in order to promote and maintain residents independence and individual residents are provided with appropriate equipment when this is required. The home is clean and hygienic and residents confirmed that a good standard is maintained at all times. Residents also said that a good laundry service was in operation. Sufficient numbers of staff are employed each day and night to meet the needs of residents. The Providers have established robust arrangements for the induction of new staff that occurs over the first six months that staff member is in post. Staff recently appointed said they had been well supported and suitable records are maintained. The staff group also receive regular training to make sure their knowledge; skills are abilities are up to date. There are some positive arrangements in place to promote safe working practices for the staff and residents. A detailed health and safety audit has also been completed for the environment that is regularly reviewed. The equipment and services at the home are also appropriately maintained and serviced. The Providers have also established policies and procedures to promote the health and welfare of residents and staff. What has improved since the last inspection?
Each prospective residents needs are assessed by the Providers to make sure the services and facilities meet the needs, preferences and choices of the person concerned. The assessments have continued to improve and generally meet the minimum standard required. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 7 The information in care plans has also continued to improve and they offer better guidance and direction for staff. Further improvement is required to make sure that residents are provided with the care and support they require. Better arrangements are in place regarding opportunities for residents to participate in recreational activities. A new activities coordinator has been appointed who is actively consulting with residents’ about their needs and choices. In addition the current arrangements in place are being reviewed. The providers have arranged for a comprehensive assessment of the environment, which has highlighted that significant improvements are required. The providers are therefore in the process of drawing up a three-year plan that will result in the refurbishment of the environment and the replacement of furniture and furnishings. The plan also includes the redecoration of the facilities. The providers have continued to regularise the numbers of housekeeping staff on duty given a shortfall has occurred due to staff illness and vacant posts. The situation continues to improve but has not yet been fully resolved. The risk management and risk assessments arrangements have improved but there continues to be occasions where risks are not appropriately taken into account. In addition some of the guidance to staff about positively managing risks an individual resident experiences need to be more detailed. Suitable arrangements for fire prevention and fire safety have also been put in place to make sure that residents and staff are safeguarded. What they could do better:
It would be beneficial for the providers to complete more detailed assessments regarding recreational and social needs and where residents are not able to direct their own care. This will make sure that residents are provided with the care, support and individualised lifestyle they require. Care plans also need to provide more detailed information about each residents social, emotional and recreational needs to make sure staff have a clear understanding of the care and support required. This will also make sure that residents have more control over their lives and are provided with a varied and stimulating lifestyle. There are occasions when the dedicated laundry staff are able to undertake their planned duties. When this has occurred the care staff have undertaken the laundry duties alongside their other responsibilities. Residents said this resulted in a decline in the standard of service. It is anticipate the current recruitment drive will help to regularise this position. This will also mean that improved arrangements will be in place regarding the laundry service. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 8 The providers should review the arrangements to access addition care staff when this is required by residents needs. This will make sure that residents are safeguarded and the standards of care are not potentially compromised. Some of the records about the management of residents’ personal allowances need further improvement in order to meet the required standard. 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. Langholme DS0000009108.V318238.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 Langholme DS0000009108.V318238.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): The standard considered was standard 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider assesses each prospective resident. Improvements are necessary to make sure the providers are able to meet the residents needs in respect of their health and welfare. EVIDENCE: The statement of purpose and service users guide has been reviewed over the last year and reflects the current management arrangements and the services and facilities provided. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 11 Prospective residents are assessed by the Provider to determine their needs, preferences and choices. The assessments also satisfy the Provider the services and facilities are appropriate to meet the needs of the prospective resident. Prospective residents are invited to participate in the assessment and the views and opinions of their relatives or representatives are taken into account. Any professionals that are contact with the prospective residents are also consulted. The assessments of need have improved following the last inspection and broadly meet the minimum standard required. In certain instances it would be beneficial to provide more detailed information about the persons recreational and social needs to make sure a varied and stimulating lifestyle is achieved. On other occasions more detailed information would benefit residents that experience more complex needs or are unable to direct their own care. Residents that have recently moved to the home confirmed they were consulted about their needs. The residents said they had been well received at the home when they were admitted and were generally positive about the manner in which the staff provided the care and support they require. Langholme DS0000009108.V318238.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): The standard considered was standard 7. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. For some residents the individual plan of care needs to be amended and updated to accurately detail their health, personal and social care needs. EVIDENCE: The registered providers are in the process of introducing a new format for recording care plans. It is envisaged that this will promote user accessibility. It is viewed the new format will also improve the staffs to access to information about the care and support each residents requires. The care planning arrangements have continued to improve following the last inspection. In certain instances further improvements are required to make
Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 13 sure that staff have the appropriate information and guidance and residents are safeguarded. There were also some instances where residents needs had change but insufficient information or guidance was provided. There were also examples where the guidance assumed the residents’ needs were well known to the staff. This places staff that has been recently appointed at a disadvantage and could compromise the residents’ wishes. The care plans would also benefit from information about each residents social and recreational needs, preferences and choices. In addition there is evidence the plans are regularly reviewed but the conclusions of the review are not always clearly recorded. Residents were generally satisfied with the care and support provided but a number commented that certain staff lacked attention to detail. The staff commented the care plans had improved and provided more reliable information about the care and support required. Langholme DS0000009108.V318238.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): The standards considered were 12 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The opportunities to participate in valued social and recreational activities continue to improve to make sure that residents’ needs and preferences are met. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. Plans are being established to refurbish the kitchen facilities given they are showing signs of wear and tear. EVIDENCE: The assessment and care planning documentation would benefit from more information about each residents social, emotional and recreational needs,
Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 15 preferences and choices. This will assist the provider to make suitable arrangements to meet the residents preferred lifestyles. Generally the residents commented that patterns of daily living were flexible and they were able to have control over their lives. Some of the residents indicated the level of control was dependant on the skills and abilities of the staff that were providing the care and support on that day. This is an area the registered manager needs to address. Following the last inspection an alternative activities coordinator has been appointed. The post holder is currently in the process of consulting with residents about their interests and is also reviewing the current arrangements in place. Residents were clearly positive about the current post holder. Some of the residents choose not to participate in the activities provided and prefer to manage their own recreational opportunities. The provider has positively responded to the requirement set at the last inspection to improve the kitchen flooring and suitable repairs have been undertaken. In addition plans are being established to refurbish and upgrade the kitchen area and facilities over the next three years. The current facilities are showing signs of wear and tear but are maintained to a good standard of hygiene and cleanliness. In addition appropriate health and safety measures are in place. All, the residents are very positive about the varied and nutritional menu that is provided. The residents said the standard of food was “excellent” and met with their preferences, choices and needs. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 16 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): The standards considered were 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place for dealing with any concerns, complaints or allegations of abuse. This makes sure that residents are safeguarded. EVIDENCE: The Providers have established a satisfactory complaints policy and procedure. Following the last inspection the Commission has received no complaints. The providers have received one complaint that has been satisfactorily resolved. Residents said there were no barriers to raising any issues or concerns with the Providers. The residents were confidant that any issues would be dealt with promptly. A satisfactory policy and procedure has also been established by the Providers for dealing with any concerns or allegations of abuse. Any issues of concern
Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 17 are reported to the statutory authorities for investigation to make sure that every reasonable step is taken to protect residents. A whistle blowing policy is also in place. This enables staff to report any concerns to a third party if they feel unable to directly raise the issue with the Providers. This provides residents with further safeguards from abuse. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 18 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): The standards considered were 19, 21, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The providers have identified the environment requires refurbishment and plans are in place to undertake significant improvements over the next three years. The plans have been prioritised and work will commence in this financial year. In the interim the providers are making every reasonable effort to provide a comfortable and homely setting for residents. EVIDENCE: The providers’ have recently commissioned a quality assurance assessment. The assessment concludes the environment is in need of refurbishment. The providers are therefore in the process of establishing a three-year plan to
Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 19 undertake the work. The plan has been prioritised and some work is due to be completed in the current financial year. This includes the refurbishment of four communal bathrooms and other priority works. Residents said they were generally satisfied with the facilities provided and the majority have personalised their own bedrooms. The home is clean and hygienic and no offensive odours were evident. Residents stated that good standards of hygiene and cleanliness were maintained at all times. Residents were also satisfied with the laundry service provided at the home. Residents said the service was reliable and a good standard was maintained providing the laundry staff were on duty. Residents stated there were occasions when laundry staff were not provided. When this occurs care staff undertakes the laundry alongside their other duties. Residents said this resulted in a decline in the service. Storage at the home continues to be a challenge but the environment was relatively tidy and recent improvements had been sustained. The manager said they were continuing to consider how the storage arrangements could be further improved. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 20 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): The standards considered were 27, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of care staff are on duty each day and night to meet the needs of residents. There are occasions when sufficient numbers of domestic staff are not on duty in order that a good laundry service is provided. Appropriate arrangements are in place to recruit new staff and provide the newly recruited staff with a suitable induction. This makes sure that residents are safeguarded. The staff group are trained to a good standard in order they have the knowledge and skills to meet residents’ needs. EVIDENCE: There is sufficient care staff on duty during waking hours to meet the minimum standards. In addition two waking care staff is employed each night to provide the care required and reliable “on call” arrangements are in place if any emergencies occur. The manager said that staffing levels continued to be reviewed and monitored and additional staff was employed when required by residents needs. Some of
Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 21 the staff commented it was difficult to access additional staff when needed. This is an area that needs consideration by the providers. Domestic staff is also employed at the home each day and this includes staff that are employed in the laundry. The providers have taken positive steps to address the current staffing deficits that have occurred due to staff illness and vacant posts. The providers continue to make every reasonable effort to address the current shortfalls. Maintenance staff is also employed and the residents said that any repairs were dealt with efficiently and competently. The recruitment selection and vetting arrangements have continued to improve to ensure the residents are safeguarded. The records of staff that have recently been recruited indicated robust arrangements are in place and that every reasonable step is taken to protect residents. Newly appointed staff complete a comprehensive induction programme to make sure they are able to provide the care and support required. Recently appointed staff said they were provided with a balanced induction and were well supported by experienced staff. The registered manager has also established an annual staff training programme so that staff have the required knowledge and skills to meet residents’ needs safely. In addition a high percentage of staff hold the NVQ 2 qualification and a number of staff are also qualified to NVQ 3 standard. Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 22 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): The standards considered were 31, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is well managed for the benefit of the residents. There are some good examples of safe working practices but the risk assessment and risk management arrangements require further improvement to make sure that residents and staff are safeguarded. EVIDENCE: Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 23 The Providers appointed a new manager who took up the post in February 2006. Following the last inspection the manager has been appointed as the registered manager. In addition the post holder has also been appointed as the registered manager for the Domiciliary Care Service that operates from the care home. The manager has extensive experience in the field of social care and is currently completing the Registered Managers Award. It is evident the registered manager has improved the management arrangements and provided a clear structure for operational staff. This has included reviewing the roles and responsibilities of senior staff. The staff group were positive about the impact of the new manager and had confidence in their skills and abilities. A senior member of staff is on duty for all waking hours to make sure that staff are well supported. On a daily basis senior staff also assist the registered manager in the coordination and delivery of care. Residents were positive about the registered manager and commented the manager had made a positive initial impact. The providers have also appointed officers to undertake regulation 26 visits each month and the Commission regularly receives a report of their findings. The Providers will assist residents to manage their personal allowances where there is no third person available to offer assistance. A record is made of each transaction and the records have improved following the last inspection but two of the records sampled were found to be incomplete. There are some positive arrangements in place to promote safe working practices for the staff and residents. A detailed health and safety audit has also been completed for the environment that is regularly reviewed. In addition the equipment and services at the home are appropriately maintained and serviced. The Providers have also established policies and procedures to promote the health and welfare of residents and staff. The risk assessment and risk management arrangements are good for the environment but continue not to be satisfactory for residents and staff. Although the arrangements have improved there still continues to be occasions where risk assessment are not completed. This potentially compromises the health, safety or well being of individual residents and staff. In addition some of the risk management plans did not provide staff with sufficient information, direction or guidance. There are also occasions when risk assessments are not undertaken as part of the assessments for prospective residents. Further Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 24 improvements are therefore required to make sure that residents are safeguarded. In certain instances there was evidence of robust risk assessments and good risk management plans had been established. The Providers have also established robust policies for fire prevention and fire safety. The records confirm the fire equipment is regularly checked and regular fire practices and training for staff have been established. Langholme DS0000009108.V318238.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 3 X 3 2 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X 2 Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement The registered persons shall not accommodate a service user unless their needs have been suitably assessed and the provider is satisfied the care home is suitable for the purpose of meeting the service users needs. A written plan must be in place for each service user that details how the service users needs in respect of health and welfare are to be met. Service Users social and recreational opportunities must be develop to reflect their choices and preferences. The fabric, decoration, furnishings and floor coverings must meet the required standard. The communal bathrooms must be redecorated and refurbished to the required standard.
DS0000009108.V318238.R01.S.doc Timescale for action 31/01/07 2. OP7 15(1)(a) 30/03/07 3. OP12 16(2) (m-n) 30/03/07 4. OP19 23(1)(a)( 2)(b)(d) 30/09/07 5. OP21 23(1)(a)2 (j) 30/03/07 Langholme Version 5.2 Page 27 6. OP27 18(1)(a) Sufficient numbers of domestic staff must be on duty at all times. Accurate records must be maintained of the personal monies the Providers assist service users to manage. Risk assessments and where appropriate risk management plans must be completed on each occasion an accident or incident occurs or there are any concerns about the safety of service users or staff. . 30/12/06 7. OP35 17(2) Sch 4 (9) 30/12/06 8. OP38 13 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP19 OP20 Good Practice Recommendations The content and decisions of service users reviews should be fully recorded. A written annual plan of redecoration and refurbishment should be in place. The alcove in the dining room should be reviewed to improve the facilities provided. Sufficient storage space should be provided. 4. OP23 Langholme DS0000009108.V318238.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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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