Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 04/09/06 for Larchwood Nursing & Residential Home

Also see our care home review for Larchwood Nursing & Residential Home for more information

This inspection was carried out on 4th September 2006.

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.

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 home has a core group of staff who care for the residents well being. Able bodied residents are allowed to maintain an independent lifestyle. The manager assesses prospective residents before admission using a basic format to record the findings. Most residents are satisfied with the medical support they receive. Money that is held for residents in the home is managed safely.

What has improved since the last inspection?

The homes service users guide and statement of purpose have been updated, but have not yet been introduced to any residents or their families. Care plans for residents have been re-written and updated and contain more information about how residents like to be cared for. However further improvement is needed because some care plans did not contain enough information about residents needs and the recording was not detailed enough. Staff were unaware of the content of the care plans. Some improvements have been made to medication practices, however, there remain areas of significant concern regarding the administration of medication. The new acting manager has a good understanding of how to protect vulnerable people. Observations made during this visit showed staff treated residents with respect. Staff confirmed they were taught about this during their induction. Decoration has improved the appearance of unoccupied bedrooms. Some corridors and communal areas have also been repainted. Some new furniture has been purchased for lounges and unoccupied bedrooms. A new bath has been installed replacing one that was badly damaged. Some improvements have been made regarding stimulation and interaction for residents. However these were minor and further improvement is required. Although the nurse call system has not been replaced it was quieter and less intrusive for residents. Induction training for new staff has commenced. Staff have not yet commenced any NVQ training, because a training manager has only just been appointed by the company. However some staff are about to register for NVQ2. The home is now using safer vetting procedures for all newly appointed staff. A new manager has been appointed. Risk assessments of the building have been completed.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Larchwood Nursing & Residential Home 133 Yarmouth Road Thorpe St. Andrew Norwich Norfolk NR7 0RF Lead Inspector Hilary Shephard Unannounced Inspection 4th September 2006 09:00 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 Larchwood Nursing & Residential Home DS0000015652.V311124.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. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larchwood Nursing & Residential Home Address 133 Yarmouth Road Thorpe St. Andrew Norwich Norfolk NR7 0RF 01603 437358 01603 702046 larchwood@bondcare.co.uk 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) Bondcare (Larchwood) Limited Position Vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (48) of places Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to forty-eight (48) Older People may be accommodated in the category OP. Up to forty-eight (48) Service Users who have a physical disability may be accommodated in the category PD, who are aged 55 years or over. No more than 48 Service Users may be accommodated. One person with dementia whose name is held on CSCI records may be accommodated. Once this person is no longer resident, the registration reverts to 48 older people. 2nd May 2006 Date of last inspection Brief Description of the Service: Larchwood Nursing and Residential Home is owned by Bondcare Ltd and is situated on the outskirts of Norwich, within Thorpe St Andrew. The home lies within easy access of a large supermarket, post office and small local shops. It is a two-storey building with access to the first floor by shaft lift and stairs. The home can accommodate up to 48 older people, 25 with nursing needs and 23 with residential needs. The service has 36 single and 6 shared bedrooms. All the bedrooms have en-suite toilets and washbasins. There is an enclosed patio area with seating and with raised flowerbeds that are accessible to wheelchair users. The home has car-parking facilities at the rear of the premises. The home informed CSCI of its charges in August 2006 and charges the following for care provision: from £338 to £525 per week. Residents are expected to pay extra for hairdressing, chiropody and personal items. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgments for each outcome group. A total of 14 requirements were made as a result of this inspection, 7 of which are repeated from previous inspections. It is of serious concern that the Commission has had to repeat requirements regarding medication. Two requirements regarding medicine availability and recording of medicines have been repeated. One requirement regarding medicine administration is repeated for the second time. The Commission continues to have serious concerns about the home being able to sustain any kind of improvement as this and previous inspections show the registered owners have not been consistent with making any significant improvements. If there is no significant improvement following the next inspection visit then enforcement action will be commenced to bring about improvement. If that is not achieved there will be no option but to cancel the home’s registration. The Commission met with Directors and Managers from Bondcare following the May 06 inspection to discuss the homes future. Bondcare have advised the Commission that they are committed to making improvements to the home and have started to put measures in place to address all the issues raised at the visit of 2nd May 2006, however this visit shows the improvements made are small and insignificant and there is no evidence that the organisation is committed to providing a good quality of care experience to older people. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The homes service users guide and statement of purpose have been updated, but have not yet been introduced to any residents or their families. Care plans for residents have been re-written and updated and contain more information about how residents like to be cared for. However further improvement is needed because some care plans did not contain enough information about residents needs and the recording was not detailed enough. Staff were unaware of the content of the care plans. Some improvements have been made to medication practices, however, there remain areas of significant concern regarding the administration of medication. The new acting manager has a good understanding of how to protect vulnerable people. Observations made during this visit showed staff treated residents with respect. Staff confirmed they were taught about this during their induction. Decoration has improved the appearance of unoccupied bedrooms. Some corridors and communal areas have also been repainted. Some new furniture has been purchased for lounges and unoccupied bedrooms. A new bath has been installed replacing one that was badly damaged. Some improvements have been made regarding stimulation and interaction for residents. However these were minor and further improvement is required. Although the nurse call system has not been replaced it was quieter and less intrusive for residents. Induction training for new staff has commenced. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 7 Staff have not yet commenced any NVQ training, because a training manager has only just been appointed by the company. However some staff are about to register for NVQ2. The home is now using safer vetting procedures for all newly appointed staff. A new manager has been appointed. Risk assessments of the building have been completed. What they could do better: The statement of purpose and service user guide needs to be provided for prospective residents and their relatives. Medication needs to be managed safely. Care plans need completion and care staff need to use them to provide care tailored to each individual residents needs. Residents need to be more involved with the care planning. Care plans need more detail about residents social needs and guidelines for staff need to be clearer. Recording in daily records needs to reflect the care that is given by care staff. Residents need more interaction and stimulation as most stay in their rooms and would like to do more. The food needs to be better, although it has improved slightly since the previous visit. A CSCI survey in July 06 indicates that 25 of residents who responded only like the food sometimes. Residents need to be allowed and encouraged to make choices about their daily lives. Although the complaints procedure has been updated and is displayed in the reception area of the home, it is not yet in residents rooms and therefore not available to them. Residents spoken with remained unsure of who to take their concerns to. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 8 The poorly maintained environment remains of concern, particularly the following areas: • • • • • • • • • • • • • • Some worn and stained armchairs and dining chairs remain in use Carpets throughout the home are badly stained, worn and dirty. The home remains dirty. Hot water is too hot in some areas and is not controlled. One toilet had no hot water. Unpleasant odours remain. The courtyard garden neglected and does not offer residents a pleasant area to sit outside. The garden furniture is of poor quality. Some radiators are damaged and the casings are falling off. Two dining tables that need re-varnishing have been covered with cloths. The cleanliness and décor in some residents bedrooms is of poor quality. More adjustable beds are needed to protect staff and residents from injuries caused by poor moving and handling techniques. One of the windows in the small dining area opposite the managers office did not close properly. The bathroom near to room 4 had a damaged and loose WC seat and the bath enamel was very rough. Staffing levels remain unchanged and although staff were being more efficient about meeting residents physical needs, residents social and emotional needs were being neglected. Residents had mixed views about whether there were enough staff or not. The nurse on duty had difficulty understanding spoken English and was unable to satisfactorily demonstrate her competence. Formal quality monitoring has not been implemented and the providers do not recognise the areas that require improvement without prompting from the Commission. 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. Larchwood Nursing & Residential Home DS0000015652.V311124.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 Larchwood Nursing & Residential Home DS0000015652.V311124.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area remains adequate. The outcome of this group of standards will be good once the home has fully updated and completed the service user guide and statement of purpose and once this has been introduced to the residents and their families. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Previous visit carried out in May 2006 found that the manager visited residents before admission and completed a basic assessment of care needs, which is kept in the residents care plan. The visit carried out September 06 found no changes have been made to this procedure. The statement of purpose and service user guide have been updated but some information is still missing from the service user guide. Once this is complete it should offer residents enough information about the home. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area has improved from being poor and is now adequate. The outcome of this group of standards could be good if the home made significant improvements to the way medicines are managed and ensured care staff and residents are involved in the care planning process. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Most care plans at the previous visit did not contain sufficient detail about residents emotional and social needs. Some improvements have been made but this has not changed significantly. The previous visit identified that staff had very little involvement in the care plans and were not using them to help them care for the residents. This has not changed. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 12 Care plans have now been re-written and updated by the deputy manager and are now written in a way that focuses on residents abilities and wishes. Risk assessments for the use of bedrails have improved and are now not being used inappropriately. Medication was inspected during a further unannounced visit on 8 September 06 by the Commissions specialist Pharmacist Inspector following up requirements made at the May 06 visit. His visit identified some improvements however, there remain areas of significant concern regarding the administration of medication. It is of serious concern that the Commission has had to repeat requirements regarding medication. Two requirements regarding medicine availability and recording of medicines administered have been repeated from the May 06 visit. One requirement regarding medicine administration is repeated for the second time from both the November 05 and May 06 visits. Observations made during the September 06 visit showed staff to treat residents with respect. They were observed knocking on residents bedroom doors and spoke to them in a kind and gentle way. A requirement has been repeated regarding care planning. Larchwood Nursing & Residential Home DS0000015652.V311124.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area has improved from being poor and is now adequate. The outcome of this group of standards could be good if the home provided residents with more stimulation and interaction according to their wishes, provided residents with choices about their daily lifestyles and provided nicer meals. This judgement has been made using available evidence including a visit to the service. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 14 EVIDENCE: The previous visit found that most residents spent a lot of their time in their rooms. During that visit very few residents were seen in the lounges or dining areas. The September visit showed this has not changed. The previous visit identified that an activities co-ordinator is employed for three afternoons per week, there was little evidence of interaction with the residents who remained in their bedrooms. Staff said they had little time to spend talking to the residents. Although the activities coordinator tries to spend more time with residents who remain in their rooms, nothing else has changed. Residents spoken with during the September visit said they join in with group activities, the activities coordinator sometimes visits them in their rooms, they have activities weekly and sometimes they are bored. The September 06 visit found that a choice of lunch was offered, but residents said they do not always get asked what they want. One resident spoke of how she goes to bed at 9pm and the staff get her up from about 8am. Care staff spoke of having to get residents up before breakfast, around 8.30 am and that these times were set. Lunch was sampled at the previous visit and again at this visit. Both meals were badly cooked, however the alternative meal had been nicely presented and most residents appeared to enjoy it. Requirements have been repeated regarding activity, stimulation, food and one made regarding choice. Larchwood Nursing & Residential Home DS0000015652.V311124.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area has improved from being poor and is now adequate. The outcome of this group of standards could be good if the home ensured all residents were made aware of how to complain and who to and if staff left in charge of the home clearly understood how to manage adult protection issues. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The previous visit found that the home had an out of date and incorrect complaints procedure. This visit found the complaints policy had been updated and displayed in the reception area of the home. However, it was not yet in residents rooms and residents spoken with were unsure of who to take their concerns to. One said “one wonders if it makes any difference”. Staff said they would refer concerns to the nurse in charge, however the nurse in charge was unsure of how to manage a serious abuse issue, but said she would refer to the manager. The manager had a clear understanding of how to manage abuse issues. One requirement has been repeated regarding complaints and one made regarding adult protection. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 26 Quality in this outcome area remains poor. The outcome of this group of standards could be good if the home improved the internal and external environment, furniture, equipment and eradicated unpleasant odours. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The previous visit found home was very dirty with offensive odours in some places. The home was shabby and had been poorly maintained and there was with no formal plan of refurbishment, redecoration or maintenance. Furniture throughout the home was stained and very worn looking. Some repainting was being done in corridors, communal areas and the unoccupied bedrooms. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 17 Residents commented in a recent CSCI survey that the toilet could be cleaner, the bedroom could be cleaned better and more often. The September 06 visit found improvements to the general decor have continued. Many areas have been repainted including some empty bedrooms. Some armchairs have been replaced and the bath that was badly damaged has been replaced. Some newly decorated bedrooms have new furniture, but not new carpets or beds. The cleaning staffs duties have been changed so one is available in the afternoons, however the home remained dirty. The manager explained she had ordered new vacuum cleaners as the existing ones did not work well. Offensive odours in and around room 17 remain. Room 17 was particularly dirty, as was the furniture. Carpets throughout the home remained stained, worn and dirty. The small courtyard garden in the centre of the home was tatty and neglected. The call bell was quieter than at the previous visit and was less intrusive for residents. Staff said how there was a lack of adjustable beds and they were having difficulty caring for bedridden residents in the divan type beds. They said they cannot put the proper moving and handling training into practice because the facilities are poor. The home has 6 shared bedrooms and the manager said that she was planning to use one vacant one as a single room. This is seen as good practice and the continued use of shared rooms should be given serious reconsideration. Requirements have been repeated regarding the environment, cleanliness and odour and one made regarding the garden. Larchwood Nursing & Residential Home DS0000015652.V311124.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): 27, 28, 29, 30 Quality in this outcome area has improved from being poor and is now adequate. The outcome of this group of standards could be good if the home provided staff in sufficient quantities to meet the residents whole range of needs, if nursing staff could demonstrate their competence and if the organisation was better at providing opportunities for staff to undergo formal training and obtain qualifications. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The previous visit found residents physical care needs were mostly addressed except for being given drinks, but their emotional and social care needs were not being met. No staff had any NVQ training. Information gathered from residents in a CSCI survey in July 2006 indicates that 12.5 thought staff were always available when needed, 62.5 said usually, 25 said sometimes. Comments made by residents were: Sometimes left wet for long periods, sometimes they take a while to answer the buzzer, Staff very good but take a long time to get to me when I ring the bell. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 19 Observations at the September visit showed staff were busy but were attentive and answered call bells quickly. Staff were having difficulty meeting residents social and emotional needs. Observations showed care staff were kind to residents and had a good understanding of their needs. The nurse on duty had difficulty understanding spoken English and was unable to competently discuss appropriate use of specific wound dressings for residents although said had done a wound care course last year. One new member of staff confirmed she was having induction and spoke of the areas covered so far. Staff have not yet commenced any NVQ training, but some are about to register for NVQ2. Recruitment practices were poor at the previous visit, however this visit showed that since the appointment of the acting manager, recruitment practices have improved significantly. One requirement regarding staffing levels has been repeated and one made regarding staff competency. Larchwood Nursing & Residential Home DS0000015652.V311124.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): 31, 33, 35, 38 Quality in this outcome area remains poor. Although improvements have been made, they are not significant enough to change the quality rating in this area from poor. The outcome of this group of standards could be good if the providers implemented formal quality monitoring and recognised areas that require improvement and showed they were consistent in improving quality of the service they provide. It could also be good if the environment was safe and consistently maintained to a good standard. This judgement has been made using available evidence including a visit to the service. Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager employed at the time of the previous visit left soon after and was replaced in August. The acting manager is a trained nurse who has applied to undertake the registered managers award (RMA). The September 06 visit found the manager was working with the deputy setting up systems for induction, supervision and care planning. The acting manager advised supervision was to commence once all care plans were completed. Formal quality monitoring has not yet been carried out. The home hold small amounts of money for some residents. Records of these were checked and the money found to be managed safely. Some safety issues were noted in the home: • Some radiators were damaged with parts of the casing falling off. • Hot water temperatures were measured in three areas and was too hot in two and cold in one. No evidence was seen of thermostatic valves being fitted to hot water taps or of hot water temperatures being measured. Acting manager advised she regularly audits the accident records. One requirement has been repeated regarding quality monitoring and one made regarding safety. Larchwood Nursing & Residential Home DS0000015652.V311124.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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Seven 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 OP8 Regulation 15, 17 Requirement The registered person must ensure that: All care plans contain assessments and guidelines relating to residents social and emotional needs. Care plans are drawn up in conjunction with the residents and/or their representatives. Staff are aware of the care plans and use them to meet residents assessed care needs. Repeated for 1st time, deadline of 31/07/06 not met. The registered person must ensure that all requirements made by the Pharmacist Inspector are complied with by the agreed timescales. Note 3 repeated requirements, deadlines of 16/05/06 not met. Timescale for action 10/11/06 2. OP9 13 22/09/06 Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 24 3. OP12 4 OP14 5 OP15 6 OP16 7 OP18 8 OP19 12, 13, 16 The registered person must ensure that appropriate activities, interaction, stimulation and meaningful occupation are provided for all residents. Repeated for 1st time. Deadline of 30/06/06 not met. 12 (2) The registered person must ensure that residents are enabled to make decisions with respect to the care they are to receive and to their health and welfare. 16 (i) The registered person must ensure that all residents receive a suitable, balanced, wholesome, nutritious diet, which is varied, properly prepared and suitable for their needs. Repeated 1st time, deadline of 31/05/06 not met. 22 (2, 5) The registered person must ensure the complaints procedure is available to all residents and their representatives. Repeated 1st time, deadline of 31/05/06 not met 13 (6) The registered person must ensure that any persons left in charge of the home understand their responsibilities regarding managing issues of abuse. 23 The registered person must ensure that: • The décor of the home is improved throughout. • All stained and worn carpets and flooring is replaced. • All stained and worn furniture is replaced. • The shower room on the ground floor is made accessible to all residents. • A plan of routine maintenance and renewal of the fabric and DS0000015652.V311124.R01.S.doc 10/11/06 10/11/06 10/11/06 10/11/06 10/11/06 30/11/06 Larchwood Nursing & Residential Home Version 5.2 Page 25 9 OP20 23 (2, o) 10 OP26 16, 23 11 OP27 18 12 OP30 18 (1,a) 19 (5, b) 13 OP33 24 14 OP38 13 (4, a) decoration of the home is produced and implemented. This requirement is repeated as the deadline of 30/11/06 has yet to be reached. The registered person must ensure that the external grounds used by residents are safe and appropriately maintained. The registered person must ensure that a good standard of cleanliness is maintained throughout the home and it is kept free from offensive odours. Repeated 1st time, deadline of 30/06/06 not met. The registered person must ensure staff are provided in sufficient numbers to enable the residents complete range of care needs to be met. Repeated for 2nd time, deadlines of 1/11/05 and 31/05/06 not met. The registered person must ensure that suitably qualified, competent and experienced persons are employed who have the skills and experience necessary to meet the needs of the residents. The registered person must complete a quality audit and ensure the Commission is supplied with a copy of the report. Repeated as deadline of 30/09/06 not yet reached. The registered person must ensure that all parts of the home to which residents have access are free from hazards to their safety. This must include regulating hot water temperatures to a safe temperature. DS0000015652.V311124.R01.S.doc 31/03/07 10/11/06 10/11/06 10/11/06 30/09/06 10/11/06 Larchwood Nursing & Residential Home Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Larchwood Nursing & Residential Home DS0000015652.V311124.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!