CARE HOMES FOR OLDER PEOPLE
Lisnaveane 790 Longbridge Road Dagenham Essex RM8 2AA Lead Inspector
Ms Rhona Crosse Unannounced Inspection 19 September 2005 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Lisnaveane Address 790 Longbridge Road Dagenham Essex RM8 2AA 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) 0208 592 0022 0208 491 8424 Mr Alfred Henry Gilmore Waddell Mrs Fiona Foo Siang Waddell, Miss Julia Patricia Waddell Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th January 2005 Brief Description of the Service: Lisnaveane is a residential property that has been converted and extended over time to provide a care home for 19 older people offering 24 hour care. The home is situated on the corner of a busy road with good transport links. There is parking in the street to the side of the property. There is limited space to the side of the building for parking in the homes grounds. The home comprises of single and shared bedrooms. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection so the home did not know the inspector was coming. The inspector arrived at the home at 09.15 and left at 4.45. The acting manager was not at the home when the inspector arrived as senior staff member assisted the inspector until the acting manager arrived. The home was last inspected in January 2005. Whilst some of the requirements set at this time have been met others have not been complied with. It is of concern to the Commission that the proprietors are not acting on the requirements met and are therefore failing to operate within the National Minimum Standards and the Care Homes Regulations 2001. As a result of this Immediate Requirement Notices have been served on the home due to the non-compliance with Regulations. Other concerns in relation to the operation of the fire alarm system resulted in the inspector calling the local fire officer out to the home due to a fire door having only one hinge in operation (the ‘rising butt’ hinge had no pin to secure the hinge together, the pin was lying behind the fire door on the floor), the result was that the fire door could not close. Also 3 other fire doors on the first floor were not operating appropriately when the alarm was tested twice, in the presence of the inspector. The fire officer will complete a report to the proprietors (copying this also to the Commission) in relation to the findings of his visit. The staff at the home had been undertaking the required weekly fire alarm tests and had recorded that the doors on the first floor were not always operating appropriately. This was not dealt with by the proprietors. Due to the concern the fire alarm engineers were contacted and asked to make an emergency visit to rectify the faults. A system of monitoring the home is to be put into place until the fire alarms and doors are in appropriate working order. An Immediate Requirement Notice has been served on the home as a result of the home putting vulnerable service users, staff and anyone visiting the home at risk in the event of a fire. The Commission are also taking advice from their legal advisors in relation to the non compliance with regulations by the proprietors and the poor operation of the home. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection?
All staff have undertaken training in the protection of vulnerable adults. Night staff have attended a fire drill. Towels are no longer stored in the bathroom where they were absorbing damp air. Some of the maintenance required throughout the home has been dealt with. The floor covering in the dining room has been replaced. Broken ceramic tiles in the kitchen have been replaced and cooking equipment has been cleaned and where necessary old items not fit for use have been disposed of. A mobile hoist has been provided to assist with the lifting of service users (although this cannot be used as staff have not had the appropriate training).
Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 7 What they could do better:
There are many areas that the home needs to improve in, both paperwork and the maintenance of the home. Staff have not received statutory training in lifting and handling, basic first aid or basic food and hygiene. This must be addressed with urgency. An Immediate Requirement notice was served on the home. Although the home has a good overall care plan identifying the needs of each service user, these are not ‘working care plans’. The creation of a ‘working’ care plan has been discussed with the manager in the past, this needs to be addressed with urgency. Each service user must have a care plan that identifies each need and shows how the need is to be met. Risk assessments although written are not always being updated, therefore some information was not current. The care plans should be updated as changes occur. From the inspection of daily records this showed that for one service user’s needs they had changed in relation to ‘wandering’, continence and dietary needs but as there is no working care plan the home cannot evidence how they are meeting these changing needs. The maintenance of the building requires attention and due to the proprietors not meeting all the requirements within the timescales set, Immediate Requirement Notices were served on the home to ensure that action is taken by the proprietors. The kitchen must be deep cleaned to remove dirt, grime and grease that has built up over walls, flooring and equipment. Chipped and cracked crockery in the kitchen should be disposed of. There was no replacement crockery for the staff to use if these items were disposed of. An Immediate Requirement Notice was served on the home as a result of this finding. Odour control in the home is poor in 4 bedrooms this must be addressed with appropriate cleaning fluids to remove the smell of stale urine. Flooring to the W.C’s throughout the building were required to have the flooring replaced as it is no longer sealed around the W.C. pans and the sides of the walls. It was a requirement at the last inspection in January 2005 that this was to be achieved by the 30/5/05 this timescale has not been complied with, therefore an Immediate Requirement Notice has been served on the home. The rooms also now require decorating. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 8 As stated in the summary the home must ensure the safety of all service users staff and visitors to the home. Due to the fire doors not closing on the first floor and one having a broken hinge the home was served with an Immediate Requirement Notice to address this. Until the fire alarm is repaired and the doors are operating appropriately the home must carryout a risk assessment to ensure the safety of service users, staff and visitors. A copy of this risk assessment and the forms used to log the checks made by staff of the hourly checks of the building must be sent to 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. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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 Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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): Standard 3 was inspected. The home does not provide the service s This standard was well met with information easily accessible from well organised files. EVIDENCE: No service user is admitted to the home without having an assessment carried out. This written pre admission assessment is carried out by the manager. Assessments from placing authorities were also observed to be held on all files. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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, 10 and 11. Standard 9 will be inspected at further inspections. Although the home has a good overall care plan identifying service users needs, ‘working’ care plans must be in place. To evidence the care that the home is providing. This standard is not well managed. Other standards in this section are well managed. EVIDENCE: The home must provide a ‘working’ care plan for each service user. This was discussed with the manager at the previous inspection that the information from the overall care plan must be broken down so that each specific need is identified, recording how this need is to be met (this is to include clear guidance on how staff carryout the task to meet each need) and a review date set for these needs to be reassessed. As changes occur to the needs of the service user, these must be recorded and the care plan changed accordingly as the needs change. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 12 From inspection of the daily records it was observed that for one service user there is now a dietary need as a food supplement is being provided. Also continence needs have changed. There was no care plan to evidence this. Health care needs are being dealt with. There was evidence of GP visits and other health professionals being sought for advice and visits. Visits to Consultants, opticians, chiropodist and dentist were recorded. In discussion with a service user it was said that “ staff help me to get dressed, they treat me with respect when they are helping me.” Staff were seen to assist service users in an appropriate manner and a good rapport was seen throughout the day between staff and service users. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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 and 15. As the home has a written care plan (but not a ‘working’ care plan a plan to identify each need, physical, medical and social) it could be evidenced from the information held what service users likes and dislikes were. However, whether they were meeting the all the needs appropriately could not be established due to the lack of appropriate working care plans. EVIDENCE: The home has a daily activities plan displayed in the hallway. Activities were taking place in line with the activity plan on the morning and afternoon of the inspection. Service users were observed to join in and enjoy the singing and dancing to the Karaoke music. Armchair exercises were taking place to music in the afternoon. In discussion with one service user it was stated that he “liked the atmosphere of the home.” One service user did not want to listen to the music and went up to relax in the bedroom. Service users were observed to have access to all areas of the home. Relatives are able to visit at any time as there are no restrictions placed on visiting times. Anyone wishing to continue to use community services would be assisted to do so (this was in evidence for one service user).
Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 14 A choice of meals was discussed as part of the inspection. Menus evidenced a choice of meals. It was confirmed by one service user that the home provided choice of meals. “ We get two choices for the main meal” “ the food is good and you get enough,” “I am able to get my own cereals as I take a pain killer early in the morning”. The ability to have a choice about going out independently was supported with a risk assessment for a service user who is having a ‘short stay’ at the home. The service user said that he would use his mobile phone if he needed assistance and the staff would come and help him when he was out if this was needed. The ability to go out and about was very important to this service user and the home is commended for enabling this service user to be as independent as possible. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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): These standards will be inspected at further inspections EVIDENCE: Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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, 21, 22, 23, 24 and 26 Some of these standards are poorly managed. The maintenance of the building is poor with requirements not dealt with from the last inspection. Due to the lack of compliance with requirements set this means that the building in certain areas does not meet the National Minimum Standards. EVIDENCE: An inspection of the building was undertaken. It was established that requirements that have not been dealt with relate solely to the proprietors, as the acting manager has no control over any budgets for the home. Immediate Requirement Notices were served on the home. These requirements must be addressed within the timescale given or further formal action will take place.
Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 17 Hallways and corridors were well carpeted. The lounges were appropriate furnished and homely. The dining room has had new flooring fitted since the last inspection. The woodwork in the dining room requires painting along the skirting boards and chipped paint was observed along the walls where chairs have rubbed against the wall. This part of the wall requires decorating. The metal strip to join the floor covering with the lounge carpet is held down with masking tape. This metal strip must be appropriately secured to the floor as this is a trip hazard. The bathroom on the ground floor identified as room 4 requires the bath hoist seat to be cleaned underneath as body fats have built up. This must be cleaned and kept clean to ensure good infection control. The wooden toilet seat in this bathroom is split and requires replacing as this is no longer suitable for use. The separate W.C.’s throughout the home have flooring that is no longer suitable as there is no seal around the lavatory pans and the seals to the walls and the plastic moulded skirting is coming away from them. This is poor infection control in these areas. It was a requirement at the last inspection in January 2005 that the flooring was to be replaced with appropriate flooring sealed around the lavatory pans. The date for compliance was 30 June 2005. An Immediate Requirement Notice was served on the home. The home must comply with the new timescale set by the Immediate Requirement Notice or further formal action will be taken against the home. There was a missing plug from the wash hand basin in the downstairs W.C. All W.C.’s require decorating. Aids and adaptations are in bathrooms and W.C.’s to aid service users who are frail. Whilst the home has a hoist to ensure safe lifting of service users who do not weight bear, this cannot be used as the staff have not had appropriate training (the issue of the lack of training for staff will be reported on in the relevant standard). It was a requirement at the last inspection that the kitchen should be deep cleaned as the walls, floor and fixed equipment had dirt and grease on them. As this requirement was also not complied with an Immediate Requirement Notice for this work to be completed was served on the home. The home must comply with the new timescale set by the Immediate Requirement Notice or further formal action will be taken against the home. There are broken tiles in the kitchen that require replacing. The rubber seal to the fridge under the worktop is broken and requires replacing (this is also an outstanding requirement). Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 18 Service users bedrooms were reasonably decorated. It was stated that service users are able to bring small pieces of furniture and personal possessions with them to make their rooms more homely this was in evidence in the bedrooms. Several bedrooms had an odour of stale urine (bedrooms 11, 19, 21, 26). A suitable carpet shampoo must be used to get rid of the odour (it was stated that the current carpet cleaner does not remove the odour despite shampooing regularly). This may be due to the carpet that is fitted, not being suitable for use in a care home where there is a continence problem. If the odour cannot be removed then the carpet will have to be replaced with a suitable carpet designed to be used in care homes. Bedroom 19 has a leaded light window that has a cracked piece of glass in it. These edges are raised and could cause a cut if a service user touched them. This pane of glass must be replaced urgently as this is a health and safety issue. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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 and 30. Standards 28 and 29 will be inspected at further The home was suitably staffed at the time of the inspection. No new staff have been employed since the last inspection. Statutory training is not being provided for staff. This is of concern to the Commission as this does not ensure the wellbeing and safety of vulnerable service users. EVIDENCE: Although some staff have completed their NVQ level 2 training as this was undertaken through a training collaborative they have to have evidence that the home has paid the staff to do this training. However it was established that the staff were not allocated any time to do this training by the proprietor and have carried this out in their own time. As staff cannot evidence the time spent it is unlikely that they will now receive the certificates. Further staff have been put forward for NVQ level 2 training. The proprietor must provide training for staff in line with the regulations. No staff have attended lifting and handling training. Although the home has a portable hoist this cannot be used for the benefit of service users as the staff have not been trained to use it. This is very poor practice on the part of the
Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 20 proprietors. All staff must have lifting and handling training and this training must be updated as often as legislation requires this. The manager is booked to attend a course on lifting and handling this month. None of the staff have attended basic first aid training or food hygiene training. This must be provided by the home. The home was served with an Immediate Requirement Notice as a result of not providing statutory training in these areas. All staff will have attended training in the protection of vulnerable adults by 20/9/05. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 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, 36 and 38. Standard 35 will be inspected at further inspections. Standard 36 is met, however the remaining standards inspected are poorly managed. There were serious shortfalls in the fire safety of the home. The fire alarm system was not operating appropriately on the day of the inspection. Appropriate action must be taken to safeguard vulnerable service users. EVIDENCE: The acting manager has applied for registration and some of the required information has been provided. However the acting manager’s CRB form has not been provided to the Commission to verify this. This has been raised as a concern with the acting manager and also the proprietor. This form must be verified by the Commission before a disclosure can be provided by the Criminal Records Bureau. The Commission will have to consider the refusal of the application for registration as manager if she does not provide the appropriate form to the Commission by 30/9/05. This refusal would have implications for
Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 22 her further employment in any role managerial role within social care. All staff have to have a CRB disclosure to enable them to work in social care. Staff are receiving formal written supervision sessions. Dates are recorded of supervision that is to take place for the month of September 2005. The home is aware that each member of staff must have 6 supervision sessions within one rolling year. The homes insurance certificate was current. The renewal date for this was April 2006. It was of grave concern to the inspector that when inspecting the premises a fire door was found to have only one hinge in operation. The pin for the ‘rising butt’ hinge lay on the floor behind the door. This fire door could not close (all the weight of the door hanging on one bottom hinge). When the fire alarm was activated the fire doors on the first floor did not release from their magnetic closures and close. The inspector requested the local fire officer to make an urgent visit to the home. The fire officer attended the home and saw the fire door with only one hinge in place. The fire officer made an inspection of the building and spoke with Mr Waddell one of the proprietors who was called to the home. The door with the broken hinge was repaired and the door was then operational. The fire officer will write a report of his findings and send the report to the proprietors, the Commission will also be provided with this report. As a result of the inspectors findings the fire alarm engineers were called to make an urgent visit to repair the faults. Until all the appropriate repairs have taken place the home are required to write a risk assessment for the home for the safety of service users, staff and visitors. All fire doors must be closed at 10p.m. and staff must make an hourly check and record their findings in each fire zone throughout the night shift. As a result of the above situation an Immediate Requirement Notice was served on the home. As the staff had been recording at their weekly fire call point checks and recording that the doors were not always closing appropriately but no action was taken by the proprietors. The Commission are seeking legal advice as to further action that may be taken as a result of this poor practice. The proprietors are required by legislation to undertaken Regulation 26 visits (unannounced) and compile a report of the operation of the home. Had they been fulfilling their duties as proprietors to an appropriate level the reporting in the fire records should have been seen and should have been acted upon. It was a requirement at the last inspection in January 2005 that they carryout these visits, compile a report and send this to the Commission. The proprietors
Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 23 have not complied with this regulation. The home was served with an Immediate Requirement Notice as a result of this non-compliance. The home’s lift has been out of service for some time. The home did not inform the Commission that this repair was causing problems and likely to take months to repair. The lift engineers have been unable to access parts for this lift as the parts are no longer in use. Parts have had to be made to enable the repair to take place, although this has not been completed as yet. The home must have an operational lift, therefore the home should not admit any new service users to the home unless they can independently use the stairs. In the interim the manager must ensure the safety of service users accommodated upstairs and carryout a risk assessment on all service users who have bedrooms on the first floor. The home must keep the Commission informed of any significant event that affects the wellbeing of service users. Failure to do so will result in formal action being taken by the Commission. As the current lift is old and parts are not available the proprietors should consider providing a new passenger lift for the home. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X 1 2 3 3 X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X 3 X 1 Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 25 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 2 3 Standard OP7 OP7 OP19 Regulation 15(1) (a) & (b) 14(2)(a) 23(2)(b) Requirement Care plans must be written for all service users needs. Risk assessments must be in place, be reviewed and changed as needs change. The broken window pane in lead light window of bedroom 19 must be replaced. Written confirmation that this has been achieved is required to be sent to the Commission. Paint the skirting boards in the dining room. Decorate the bottom half of the walls in the dining room where chairs have scraped the paint off. Secure the edging strip to the floor in the doorway of the dining room/lounge. Decorate the W.C. walls and woodwork in all W.C.’s throughout the home. Replace the flooring to all W.C.’s throughout the home and replace the moulded plastic skirting. An Immediate Requirement Notice was served as the compliance date for this
DS0000027906.V251095.R01.S.doc Timescale for action 07/10/05 07/10/05 07/10/05 4 5 OP19 OP19 23(2)(d) 23(2)(d) 30/10/05 30/10/05 6 7 8 OP19 OP21 OP21 23(2)(b) 23(2)(d) 23(2)(b) 28/09/05 30/11/05 30/09/05 Lisnaveane Version 5.0 Page 26 9 10 11 12 OP21 OP21 OP21 OP26 23(2)(b) 23(2)(b) & 13(3) 23(2)(d) 16(2)(k) 13 OP30 18(1)(c)(i )&13(4)(c ) 14 OP30 18(1)(c)(i ) 15 OP30 13(4)(c) 16 OP30 18(1)(c)(i ) 17 18 OP31 OP33 9(3) 26 outstanding requirement was 30/5/05 Replace the broken tiles in the W.C Replace the cracked toilet seat in the downstairs bathroom (room 4) Replace the missing plug in the W.C. (room 7) Remove the odour of stale urine from the carpets in bedrooms 11,19,21 and 26. By using an appropriate carpet shampoo designed for the purpose. Or replace the carpet (with carpet designed to be used in a care home) if the odour cannot be removed. Staff must have lifting and handling training by a qualified trainer. An Immediate Requirement Notice was served as a result of the finding at this inspection. All staff must be trained to use the portable hoist by a qualified trainer. An Immediate Requirement Notice was served as a result of the finding at this inspection. All staff must be trained in basic first aid. An Immediate Requirement Notice was served as a result of the finding at this inspection. All staff must have food and hygiene training. An Immediate Requirement Notice was served as a result of the finding at this inspection. The acting manager must provide her CRB form for verification by the Commission. This is an unmet requirement from the last inspection. The proprietors must carry out a visit to the home and compile a report on the operation of the
DS0000027906.V251095.R01.S.doc 30/11/05 30/09/05 30/09/05 30/12/05 30/10/05 30/10/05 30/10/05 30/10/05 30/09/05 30/09/05 Lisnaveane Version 5.0 Page 27 19 OP38 23(4)(c)(i v) 20 21 OP38 OP38 13(3) 13(4)(c) 22 23 OP38 OP38 23(2)(c) 23(2)(c) 24 OP38 14(2) 25 OP38 13(3) home on a monthly basis and send a copy to the Commission. An Immediate Requirement Notice was served as the compliance date for this outstanding requirement was 30/5/05. The home must ensure that the fire alarm system is in working order at all times. Repairs/replacements must be carried out as necessary. An Immediate Requirement Notice was served as a result of the finding at this inspection. Provide written confirmation that the Legionella test has been carried out on the water system Have the 5 year electrical safety check carried out on all wiring and provide written confirmation that this work has been undertaken. The home must have an operational lift. Service users must not be admitted to the upstairs bedrooms if they are not able to use the stairs. Carry out a risk assessment for all current service users who have bedrooms on the first floor and have to use the stairs until the lift is repaired. Replace all the chipped crockery as this should not be used as chips and cracks harbour germs. 30/09/05 07/10/05 30/11/05 30/10/05 30/10/05 30/09/05 30/09/05 Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations Consideration should be given to replacing the old passenger lift. Lisnaveane DS0000027906.V251095.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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