Inspection on 25/07/06 for Laurence House

This inspection was carried out on 25th July 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.

Other inspections for this house

Laurence House 05/07/07

Laurence House 09/11/05

Laurence House 05/07/05

Laurence House 16/12/04

Laurence House 13/08/04

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

CARE HOMES FOR OLDER PEOPLE Laurence House 5 Cliffe Road Bradford West Yorkshire BD3 0JP Lead Inspector Valerie Francis Unannounced Inspection 25th July 2006 10:30 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 Laurence House DS0000033600.V297376.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. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laurence House Address 5 Cliffe Road Bradford West Yorkshire BD3 0JP 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) 01274 641367 01274 627147 City of Bradford Metropolitan District Council Department of Social Services Care Home 29 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (29) of places Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for DE is specifically for the service user named in the application for variation dated 14 March 2004 9th November 2005 Date of last inspection Brief Description of the Service: Laurence House is a single storey, purpose built Local Authority residential and day care resource centre for older people with dementia. In addition to day care, the home provides residential and respite care, without nursing, for 29 people of both sexes. Day care is not regulated and therefore is not inspected. The residential part of the home functions from three different wings. Each wing has a lounge, dining and kitchen area, all leading to a central lounge. A multi-cultural lounge is also provided. The layout of the home makes it easy to get to all wings from the central lounge area. Digital locks are fitted around the home and on all exit routes making sure that service users are safe. Bus stops are nearby and there is a small car parking area at the front of the home. Nearby there are shops, chemists, pubs and a local park The weekly fees are from £12.95p per night and up to £62.24 per night these charges do not include hairdressing or chiropody. The home provides care to people whose first language is not English. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Survey cards were distributed to relatives/ visitors and residents in order to give people the opportunity to comment on the services provided by the home. At the time of writing this report three resident and nineteen relatives/visitors surveys had been returned to the CSCI. They showed that overall people were satisfied with the standards of care provided. But they also showed that some people thought there were often not enough staff on duty, there were not enough activities provided, many were not aware of the complaints procedures or that they could ask to see copies of the homes inspection reports. Relatives/visitors surveys did say that they were made to feel welcome and could visit in private if they wanted to. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by the assessed quality rating of the home. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a visit to the home. All regulated services will have at least one key inspection before 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people living at the home. All core National Minimum Standards are assessed and this provides the evidence for the outcomes experienced by residents. At times it may be necessary to carry out additional visits, which might focus on specific areas like health care or nutrition and are known as random inspections. This visit was unannounced and carried out by one inspector over two days. It started at 10.30am, finished at 5.00pm on the 25h July 2006, and was completed between 1:30pm and 4:00pm on the 31stJuly 2006 with feedback given to the management team at the end of the inspection. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents and to see what progress had been made meeting requirements made at the last inspection. Information to support the findings in this report was obtained by looking at the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Records in the home were looked at such as care plans, staff files, and complaints and accidents records. Residents, their relatives and visitors were spoken to as well as members of staff and the management team. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 6 CSCI comment cards and post-paid envelopes were sent to the home to be given to residents and their relatives four weeks before the visit was made. What the service does well: What has improved since the last inspection? A new manager has been appointed for the home and the registered provider has taken action to register this person with the CSCI. The appointment will make sure that there is continuity in the management of the home, which would provide staff with clear leadership. It was identified from speaking to staff and visitors, and from comments made in survey cards, that they were glad to have a permanent manager at the home. They were positive about the changes that had been made and said that communication in the home was better and that they felt supported by the management team. This would result in better outcomes for residents in the home and a more positive and supported staff team. Over 50 of care staff have achieved qualifications equivalent to NVQ (National Vocational Qualification) 2 or higher. Good progress has been made with meeting outstanding requirements and recommendations, which have reduced from twenty to eleven. The management team were aware of those that had not been met yet. The manager said she would be making all effort with the home’s management Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 7 team and line management to the home to resolve the remaining requirements and recommendations. A plan was in place for the replacement of the home’s “nurse call” system that would meet the needs of the home. Target dates for meeting them were in place. When feedback was given at the end of the inspection, comments made by the manager showed commitment to making sure that the home would be run in the best interests of the residents. The emergency lighting are checked on a monthly basis for which a record is kept. 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. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 8 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 Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 9 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): 1 & 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. People who wish to use the service have access to information about the home, but the assessment must be in more detail so that all potential risks and care needs are identified. EVIDENCE: People who would like to use the service have the opportunity to access information about the home regarding type of care provided by the home, giving them information about the training and qualification of staff and the building. The home service user guide is available to people living at the home a copy of the last inspection report was displayed in the main entrance on the notice board. One of the “wing managers” or the home manager carries out the assessments of new residents. Emergency admissions are taken if there is a vacant room. When possible the manager carries out an assessment to ensure enough information is collected Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 10 before admission. The assessments records seen by the inspector did not have any details of history of falls, so that plan of action can be put in place for the management and minimising of the identified risk. No information on hobbies, cultural needs, person safety, social contacts and any involvement of relatives. The home provides short stay to people who use the respite service, which is mainly the service users’ from the Day Care Centre. The home carries out an assessment the inspector was told that no resident is admitted without a copy of the social worker or a multidisciplinary assessment given to the home. The manager said there is a new document, which will be used for the assessment and care planning process. Laurence House DS0000033600.V297376.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 & 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. Although some there was good assessment information, the care planning process was seen as poor, as there was no real indication on care files that residents, relatives, or persons involved in the residents care had been consulted in the care planning process. It is acknowledged that a new format to record care plan was being introduced. EVIDENCE: During this inspection several concerns were identified with regards to the care records and the care planning process. Three residents care files were inspected. At the last inspection in November 2005 several shortfalls in care plans were identified. These were still the same. One person has been a resident in the home since the 2003 but no real care plan was in place, that would give staff an action plan to follow to meet the individual care needs. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 12 It was noted that risk assessments for moving and handling and skin risk assessment had been carried out, but there was no plan in place of what action was to be taken to minimise the identified risks. There was evidence that reviews had been carried out with family involvement but again no plan in place of any agreed changes made. One resident who was admitted to the home early in the year had an assessment, which identified the care needs. This person also had an updated assessment carried out by the Social Worker a nutritional risk assessment had also been carried out, but there were no plan in place of how any identified risks and care needs would be meet by the staff at the home. Generally residents and relatives were satisfied that their health and personal care needs were being met, and felt the staff were kind. Residents are helped to get access to equipment such as wheelchairs. Privacy and dignity are respected. All staff had had training on moving and handling, however assessments were not always carried out for all residents. Records were available showing the involvement of district nurses, and a separate care file is kept by them for each resident. There was no information of the care provided to residents’ included in the care plan. A record is kept of contacts with other health care professionals. There is a designated officer on each wing of the home, who co-ordinates safe handling of medication. Medication is administered by a senior member of staff on each shift for each wing. Staff have had training on safe handling of medicine and access to the medicine policy procedure. Staff have access to detailed information to ensure that residents will be treated with care, sensitivity and respect during their last days and that residents are to be enabled to make their own choices about the care they wish to receive. The inspector was told that relatives are involved in the care of their relative with support from staff in the home and other involved healthcare professionals during this time. However, information is needed in care plans to make sure that the dying persons needs and wishes are provided, and reviewed regularly. It is recognised that relatives and staff may require support and counselling during this time. Laurence House DS0000033600.V297376.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 is adequate. This judgement has been made using available evidence including a visit to the home. The home offers a reasonable range of in-house social activities, however more needs to be done to make sure that activities programme takes account of the needs the specialist needs of the residents. Residents are supported in keeping in touch with their families and friends. More work needs to be done towards creating an environment where residents can exercise choice and control over their lives. The home provides wholesome and appetising meals and the menus are varied; residents said they enjoyed the food. EVIDENCE: The home offers activities, which are carried out by an outside agency and a designated member of staff activity organiser who also carry out activities with people at the day centre. The minibus on site is mainly for the day centre service users’. Although during the inspection some staff were observed involving residents in social activities, it would appear that more effort is needed to involve all residents in some form of activity of their choice, as it was noted that some appeared to be bored. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 14 There was no written information seen in any of the three care plan inspected that identified that residents or relative had been consulted on the type of pass time activities they liked, or how they like to spend their time. Residents also have the opportunity to take part in the day centre activities and it also gives them the opportunity to mix with people from the community. There are no restrictions on visiting and some relatives visit every day. Residents are able to see family in the privacy of their room. The manager said most residents relatives have keys for their relatives bedrooms, however there was no evidence in the care records looked at to indicate this. Some visitors use communal sitting areas when they visit. The manager said relatives had been made aware of the opportunity to have access with their relatives to care files, and that they are also encouraged to have involvement in the care planning process. This was only evidenced in one resident’s care file that a relative had been involved. Comments made by relatives during the discussion and information in survey cards returned to the CSCI office said that they are kept informed of matters affecting their relative and, are consulted and able to take part in the care planning meetings. Laurence House DS0000033600.V297376.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 7 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home’s complaint procedure is accessible to visitors to the home. There is not enough information to indicate that complaints are closed. There are systems in place to ensure that residents are protected. EVIDENCE: Although the complaint procedure is displayed in the home on a notice board and some relatives and other visitors are aware of it, the survey information received from relatives indicated that they are not aware of the complaint procedure. Arrangement had been made for the manager to attend a course on handling complaints. A poster is displayed in the home, informing visitors of adult protection and contacting the manager. Advice was given to the manager that other contact information should also be displayed. Discussion with staff revealed that they were confident of the procedure to follow if they were aware of any incident or an alleged abuse occurring. Training information showed that some staff had had adult protection training with on going training so that all staff employed at the home had attended the training. As part of the recruitment and selection by the Local Authority all staff have a Criminal Records Bureau (CRB) check before taking up employment. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 16 Some of the staff team had undertaken training on handling and aggression. The inspector was told that this would be on going and there was a plan in place for all staff to have training on aggression and restraint. All staff have access to the whistle blowing procedure and was given a copy of violence at work policy procedure. As a matter of good practice a record of signatures is kept to indicate they have been given a copy of the policy procedure. Laurence House DS0000033600.V297376.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. More effort needs to be made to provide the people living at the home with an environment that would allow them more freedom to all communal facilities i.e. toilets and their bedrooms easily identified. The dining areas appeared to lack warmth and a feel of homeliness. EVIDENCE: The manager said that carpets had recently been deep cleaned. There was no malodour detected through the inspection of the premises. The home was generally clean to a good standard. Although dining and sitting areas were clean, there was lack of a homely feel. This was fedback to the manager who said plans were in place for each dining and kitchenette area to be refurbished and replacement of furniture, which is part of the overall major refurbished plan for the home. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 18 During the course of the inspection of the premises several issues were noted. Some of the extractor fans, which included the kitchen, needed cleaning. Decanted fluid was seen in a bottle without any label, and was seen in area, which was accessible to residents. The call system in the home at the time was not working; the manager said there was arrangement in place with the local authority works department for a replacement. After the inspection a representative from this department rang the inspector with regards to the time and type of system to be fitted in the home. Although residents’ bedrooms were clean and some were personalised, the wash hand basin splash back was showing signs of wear and tear and needed replacing. Laundering of soiled linen appeared to be carried out as per infection control procedures. Staff spoken to, said that they had undertaken the induction course, which include infection control. They had also had COSHH (Control of Substances Hazardous to Health) training. Although risk assessments was carried for the premises out, not all areas that could be a potential risk to residents had been assessed. It was noted that there was a fire evacuation plan in place and a place of refuge earmarked. Laurence House DS0000033600.V297376.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 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 is adequate. This judgement has been made using available evidence including a visit to the home. The new proposed staffing levels should provide residents with enough staff to meet their needs. Residents are protected by the homes’ recruitment procedures and staff are supported in developing their skills and knowledge to meet the needs of the people in their care. EVIDENCE: Plans are in place for an increase of staffing levels over the twenty four hours. However the manager must make sure that currently there are enough staff to meet the needs of the people living at the home. One person at time of the inspection requires one to one staff supervision by staff. There are regular staff meetings for the management team at the home and all staff. Written minutes are kept of these meetings, which gives the manager the opportunity to discuss management issues, and for staff to discuss matters relating to the residents and their work issues during their meeting. Although there were several staff vacancies, the manager said these posts had been filled, but she was awaiting references and CRB checks. There was no action plan for staff training available at the inspection. The manager was asked to send a copy to the CSCI area office when completed. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 20 Information provided by the home showed that 65 of care staff have an NVQ (National Vocational Qualification) at level 2 or above. This exceeds the ratio recommended by the National Minimum Standards, which is 50 . The staff files looked at showed that the required pre-employment checks had been carried out before new staff started work in the home. Induction training is given to all new staff ensuring that they have training to meet the needs of the people in their care. Staff training is given using the skills for care. Not all of the files seen had job descriptions, staff confirmed that they had received a job description, with the application for the job. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 21 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 is adequate. This judgement has been made using available evidence including a visit to the home. The new manager has the experience and the qualification to carry out her role, which should provide staff and residents with clear leadership and stability. EVIDENCE: Since the last inspection there has been a change in the temporary management to the home, after application and interview the temporary manager was successful in gaining the post. The newly appointed manager had been in post as manager for five weeks. She has several years experience working with the client group and has registered to undertake the Registered Managers award and NVQ 4 in management. The application form for the registration has been sent to her employers. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 22 One of the” wing managers “ has also Registered Manager Award (RMA) and NVQ 4 all senior care workers has attained NVQ 3. There has been some instability with regards to the management of the home in the past, however the staff said they now hope they can settle down knowing there is someone permanent at the “helm”. The manager intends to apply for registration, to become the registered manager for the home. The manager said she operates an open door policy and is accessible to residents, relative and staff. During the course of the inspection of records, the accident records were inspected. It was noted that there was a high proportion of falls, but not at any specific time, the manager said she was aware of this and will be looking at ways to resolve this. A record was seen for the health and safety checks carried out in the home. All of the home’s management team, which also include night staff have completed a First Aid course. All staff have had moving and handling training, there is system in place to make sure that this is carried out. A high percentage of residents’ relatives handle their financial affairs. For those residents who do not have any relative or cannot handle their own affairs, this is carried out by Social Services Department. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X 3 X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 X X 2 Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement All service users must have a care plan that sets out in detail the action which needs to be taken by staff to make sure that all aspects of the health, personal and social care needs of the service user are met. Service users and/or their representatives should be invited to contribute to the care plan. This is unmet from inspections on 16th December 2004 5th July 2005 and 31st January2006 2 OP2 5.3 The registered provide must 30/11/06 provide all resident which include people on short stay with a contract showing the arrangement made. Risk assessments, showing 31/10/06 actions taken to reduce risk must be in place when risk is identified. This is unmet from an inspection on 5th July 2005 and 31 January 2006. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 25 Timescale for action 31/10/06 3. OP7 13 (4) 4. OP8 15 (1) 17(1)(a) A pressure area care plan must be in place for all service users at risk of developing a pressure sore. A record must be kept, within the care plans of those service users who develop a pressure sore, noting: a record of all community nursing visits. A record of the person’s condition and treatment. This is unmet from an inspection on 5th July 2005 and 31 January 2006. 31/10/06 5. OP27 18 (1) (a) The registered provider must make sure that staffing levels meet the needs of the service user. This is unmet from the inspection 31 March 2006. The service user guide must include: The contract. This is unmet from the inspection on 5th July 2005 and 31 March 2006. 31/10/06 6. OP2 5 (b) (c) 31/10/06 7. OP12 16 (2) 8. OP33 24 (1) (b) All service users must have access to activities to suit their individual needs and preferences. This is unmet from the inspection on 31 January 2006. Feedback from the Quality assurance questionnaires must be analysed and used to inform future planning and improvement of the home. And out come information made available to families and others DS0000033600.V297376.R01.S.doc 31/10/06 30/11/06 Laurence House Version 5.2 Page 26 who had an input in the survey. A copy must also be sent to the CSCI local office. 9. OP35 20 The registered provider must 31/10/06 demonstrate how each individual service user will receive any interest applicable to their individual savings. Last timescale 31/03/06 All effort must be made to 31/10/06 ensure that resident’s health and welfare is protected at all time with robust monitoring and plan of action for those at risk of falling. 10 OP38 13 (4) (a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 5. Refer to Standard OP38 Good Practice Recommendations All accident records should provide a clear and detailed record of how and when the accident happened, the name of any witness to the accident, and the outcome of the accident. If the accident was not witnessed a record should be made of when the person was last seen and by whom. Monthly analyses should take place and take into account where and when accidents occur in order to identify any patterns or trends. Accident recording should comply with the requirements of the Data Protection Act. 8. OP38 A training matrix should be developed so that it is easy to identify when mandatory training updates, including fire training, moving and handling, infection control and food hygiene are due. Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 27 Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Laurence House DS0000033600.V297376.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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