Inspection on 18/12/06 for Little Hayes

This inspection was carried out on 18th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Little Hayes 27/09/05

Little Hayes 13/05/05

Little Hayes 03/12/04

Little Hayes 28/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Little Hayes Church Hill Totland Isle Of Wight PO39 0EX Lead Inspector Liz Normanton Unannounced Inspection 18th December 2006 09:30 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 Little Hayes DS0000012508.V315955.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. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Hayes Address Church Hill Totland Isle Of Wight PO39 0EX 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) 01983 752378 01983 759785 Mr David Burn Mr Christopher John Negus James Amanda Jayne Saunders Care Home 26 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (7) Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Little Hayes is a Residential Care Home that offers care for twenty-six elderly residents. It is situated on the outskirts of Totland and is within walking distance of both the local amenities and the sea. It is owned by Mr David Burn and Mr Christopher James and is managed by Mrs Amanda Saunders. All the residents are accommodated in single rooms, twenty-one of which have ensuite facilities. A number of the rooms to the front of the building offer views of the sea. The property is a building of some character that sits in its own well-maintained gardens. There is outdoor seating strategically placed around the outside of the building. The home has two passenger lifts that provide access to the first floor. Weekly Fees Range From: £440.00 to £520.00. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 18/12/06 and focussed on what the commission considers to be core standards for a care home for older people as defined in the Department of Health (DOH) National Minimum Standards. The information in this report has been collected from a variety of sources, which includes feedback from seven returned resident’s questionnaires, feedback from three relative questionnaires, feedback and comments from two GPs who have patients at the home, a visit to the home, discussion with several residents, manager and staff. Four residents’ care files and two staff files were audited. The home has been under new management since 14th September 2006 following the sad loss of Mrs Julia Burn who had successfully managed the home for many years. Mrs Amanda Saunders is the new manager and has demonstrated that she is maintaining the high standard of quality provided previously. Comments from residents indicated that the majority are very satisfied with the service the home provides. What the service does well: Prospective residents and their representatives are provided with the homes information pack, which contains all the information for them to make an informed choice. Each resident is provided with a contract of the terms and conditions of the home. The home will not admit any prospective residents until they are satisfied that the individual’s needs can be met. All residents have a comprehensive care plan. The health and welfare of the residents is paramount and everybody has access to health provision and support. There are a variety of activities available to provide social interaction and mental stimulation for the residents. Residents are encouraged to maintain their independence and make choices on how they wish to live. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 6 The food is of a good quality and residents are offered alternative choices. Residents are protected from harm and the home has a robust effective complaints procedure. The home provides the residents with a homely environment with comfortable well - decorated surroundings. Each, resident is provided with their own room in the main fitted with an en-suite and they are able to personalise the room to their taste. The staff team is well established with many of the carers having worked in the home for many years and have a wealth of experience of caring for the needs of older people. The home is well managed and administered by a competent experienced qualified manager. What has improved since the last inspection? What they could do better: With regards to the propping open of the dining room door the home is required to install a self-closing door mechanism to this if they wish it to be held open at periods. Fire doors should never be propped open. The home is required to fit window restrictors to all rooms on the first floor which have a drop to the ground. A number of radiators still require covering as they can be considered a health hazard if a resident falls against them they can become badly burned. Unpainted radiator covers in the home should be painted as they look unsightly. Care plans should be reviewed monthly and the home should encourage those residents with capacity to be involved in the review. The manager may wish to consider updating staff files with the obtaining and renewal of Criminal Record Bureau Checks. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Little Hayes DS0000012508.V315955.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 Little Hayes DS0000012508.V315955.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: In speaking with a resident who was recently admitted they said “ I had written information about the home before I moved in and I am happy with the care”. In discussion with the manager they reported that they are currently updating the statement of purpose and service user guide to reflect the change in management. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 10 In written feedback from seven residents they confirmed that they are in receipt of a contract. In discussion with the manager they reported that they were responsible for meeting prospective residents in their homes or at hospital and undertook a needs assessment to ensure that their needs could be met by the home. Four residents files were viewed and contained comprehensive needs assessments. Little Hayes DS0000012508.V315955.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives is based on their individual needs however the home should encourage residents to become involved in the drawing up and review of their care plan to ensure they are satisfied with the content. The principles of respect, dignity and privacy are put in to practice. EVIDENCE: There was evidence on four residents files viewed that each person had a comprehensive care plan. In discussion with the manager they reported that they and senior care staff are responsible for the drawing up and reviewing of care plans. Residents are not currently involved in the care plan review and care plans are not being reviewed monthly. The home does not have a keyworker system. In discussion with a member of staff they reported that they Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 12 thought the information held in care plans was informative and that they had a handover at the start of each shift to pass on information about residents needs. A record of residents health needs are recorded on their individual files, each resident is registered with a GP. There was evidence of GP & District Nurse visits. Care staff support residents to attend hospital appointments. A chiropodist visits the home every six weeks. At the time of the inspection visit one resident was being supported to attend a hospital appointment. A record is kept of resident’s appetites to ensure that they have the nutrition they require. In discussion with the manager they reported that residents are able to access local optician’s and dental practices for vision and dental treatment and that a dentist does also visit people in the home. In written feedback from seven residents all confirmed that their medical needs are met by the home. And comments were returned by two GPs who have patients living at the home and both were happy with the service provided to their patients with one reporting that the home provided excellent all round care. The home had robust policies and procedures for the storage and administration of medication. Medication in the home is stored appropriately and there is safe storage for controlled drugs. There were no controlled drugs in the home at the time of this inspection. The inspector viewed the Medication Administration Records (MARS) and found that they had been completed accurately. Seven staff including the manager are designated as responsible for the administration of medication and have had medication training. The inspector observed a member of staff in the administration of medication and noted that they gave a person tablets using their fingers, instead of using a small pot or spoon this matter was discussed with the manager who agreed to discuss with the member of staff. The home has a policy and procedures in respect of resident’s rights. Care staff, were observed treating residents with dignity and respect and in discussion with several residents they stated that they felt that their rights were upheld. In discussion with a member of staff they reported that residents are visited by GPs and district nurses in the privacy of their own rooms. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their lifestyle and keep in contact with family and friends. There is a choice of social, cultural activities for residents. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: In discussion with the manager they demonstrated that they had recognised that there were very few activities for residents at the home and have introduced new activities, which includes a music man, the independent arts company, chair exercises, & reminiscence sessions. The weekly activities are displayed on a notice board in the reception area. The home was planning to have a magic show on the 17th December 2006 and a New Years Eve Party to which relatives and friends would be invited. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 14 The chair exercises should have been undertaken on the day of the inspection however the member of staff responsible for this activity was not on duty. It was suggested to the manager that other staff are trained to facilitate activities provided by the home to ensure that residents do not miss out. Residents have contact with the wider community. Residents with capacity are able to come and go from the home as they please. The home is visited regularly by relatives, friends, GPs, district nurses, the hairdresser visits fortnightly and the chiropodist visits every six weeks. In discussion with the manager in relation to how the home meets peoples spiritual needs they reported that a local priest visits two residents fortnightly to give Holy Communion and one resident goes out to church. A local vicar is able to visit the home on request. Residents’ individual spiritual needs are documented on care plans. Residents are able to make day-to-day choices in respect of what time to raise and retire, what to wear, how to spend their personal allowance, choice of activities, meal choices, (this list is not exhaustive). Residents were observed exercising their rights to make choices. In discussion with the cook they reported that the menus are planned around residents likes and dislikes and can cater for those with specialist dietary needs. The cook provides a four weekly rotating menu. The menu offers a wide variety of choice and all meals are of nutritional value. The cook was happy with the management of the food budget and stated that she is given everything she asks for. The home has a pleasant dining room where residents can choose to have their meals and meals can also be eaten in the privacy of resident’s own bedrooms or in the lounge. In discussion with the manager they explained that a choice of cereals is offered at breakfast, however if a resident preferred a cooked breakfast this could be arranged. The majority of residents spoken to at the time of the inspection stated that they liked the meals. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to the complaints procedure however they rarely complain about the service as matters are dealt with immediately. Residents are protected from abuse and have their legal rights protected. EVIDENCE: In discussion with the manager they reported that they are reviewing and updating the homes complaints procedure. The home had a complaints record book. The homes ethos is to consult with residents on a daily basis and to deal with minor issues to ensure they do not escalate in to a formal compliant. In written feedback from seven residents six commented that they knew how to complain whilst one said they had never had to make a complaint. Comments from residents, indicated that they feel well cared for at the home and feel listened to. The home has an adult abuse policy and procedure, which needs some minor alterations to comply with the Isle of Wight Adult Protection Guidelines. In discussion with the manager they reported that they and four staff have completed adult abuse awareness training and that there are plans for all staff to undertake this training. The home has obtained a copy of the Department of Health “No Secrets” guidance. Little Hayes DS0000012508.V315955.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to move around the home independently. Some areas of the home are in need of maintenance and refurbishment but overall the home was safe, clean and comfortable with pleasant surroundings. EVIDENCE: The location and layout of the home is suitable for its stated purpose. In discussion with the manager they reported that they have spoken to the proprietors asking for them to employ a maintenance person. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 17 It was noted that several radiators around the home did not have radiator covers and some radiator covers had not been painted and looked unsightly and did not blend with the rooms furnishings. The dining room door had been propped open with a large bell to provide staff and residents easier accessibility. There was evidence that there had been a leak into the dining room and the ceiling was cracked, stained and damaged in discussion with a member of staff they reported that there were plans to redecorate the dining room in 2007. In discussion with a member of staff they reported that there were plans to upgrade the bathroom on the first floor. It was noted that windows in several bedrooms on the first floor were not fitted with restrictors. A window on a landing had a sign on saying “DO NOT OPEN”. This was discussed with the manager who reported that the window was broken and there are plans to upgrade all windows in the home. The gardens are well maintained and were tidy, safe, attractive and accessible to service users. The homes procedures for minimising the risk of spread of infection are robust. The laundry floor has an impermeable floor covering, soiled clothes are washed separately in a specialist red bag, the washing machine has a disinfection programme. All residents are advised to label or name their clothing so as to prevent people wearing the wrong clothes. The home provides staff with protective equipment. All staff had completed training in infection control. Returned comment cards from three relatives and seven residents stated that the home is always clean. Little Hayes DS0000012508.V315955.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that staff, are trained, skilled and employed in sufficient numbers to fill the aims of the home and meet the changing needs of the residents. EVIDENCE: The home can demonstrate that it is very good at retaining staff and this has resulted in the home having an established staff team. Residents clearly benefit from this as it gives then an element of continuity and this has enabled them to develop positive relationships with the staff. In speaking with several resident’s one said, “the care is marvellous”, and a couple said “the staff are excellent”. Staff rosters demonstrated that there are sufficient numbers of staff on duty at each shift with a range of experience, knowledge and qualifications. Returned comment cards from seven residents and in discussion with several residents in the home the majority felt that the staffing levels were appropriate. The pre-inspection questionnaire completed by the manager and returned to CSCI indicated that seven of the care staff have now completed a National Vocational Qualification (NVQ) level2 or above in care. The manager has plans Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 19 to increase this number and arrangements have been made for all unqualified care staff employed at the home to commence NVQ training in 2007. The inspector looked at two staff files and found that there had been some errors made historically in the recruitment procedures of these staff. In discussion with the manager they demonstrated that they had picked up on these and would ensure that all future persons employed at the home will go through a robust recruitment procedure. In discussion with the manager they asked what the timescales were for renewing Criminal Record Bureau (CRB)s, the inspector explained that there are no given timescales however the manager might want to consider undertaking CRB checks for all the staff to ensure that there has been no change to their status as fit persons to work with vulnerable adults. In discussion with the manager they reported that they had developed an employee training record, which was to be implemented. There was evidence that staff receive mandatory training, which includes, moving & handling, health & safety, infection control, fire safety, infection control, food hygiene and first aid. In addition to this some staff have had training in understanding Parkinson’s, Adult Protection, and Falls Prevention. In discussion with a member of staff they confirmed that they had received training from the home and that they were due to start the NVQ level 2 training in 2007. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,& 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The home is effective quality assurance systems, which have been developed by a qualified competent manager. EVIDENCE: There has been a change in manager since the last inspection the new registered manager is called Mrs Amanda Saunders. The manager has worked at the home for twenty years and before taking up the post of manager she had been working in the home as deputy manager. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 21 The manager has completed the NVQ in care at level 4 and hopes to complete the Registered managers Award in early 2007. In addition the manager has undertaken adult abuse awareness, training course and refresher training in all mandatory areas. There are clear lines of accountability within the home, the manager has overall responsibility for the management of the home and is supported by a deputy and senior care staff. The manager is responsible for managing only one registered establishment. With regards to quality assurance the manager has introduced a service user feedback questionnaire on admission to the home and a questionnaire on living in the home. Four completed samples of each questionnaire had been signed by residents and were sent to CSCI as evidence prior to the inspection visit. The outcome was that two residents were very satisfied with the service and two were quite satisfied with the service. The manager has spoken to the proprietors and explained to them that due to the change of management they will now have to undertake monthly monitoring visits to the home and keep a record of the visits at the home. The manager has begun to review and update the homes policies and procedures. In discussion with staff they reported that they could raise issues, concerns etc with the manager but have not received formal supervision. As the manager is new in post they have been focussing their attention on other arrears to maintain and improve the quality of the service and will begin to implement formal supervision in 2007. The home does not have an annual renewal plan however the manager reported that they are aware that some areas in the home are due for renewal and will raise this with the proprietors. Repairs to the home are undertaken as required. The home has procedures in place for the safe keeping of resident’s monies. The manager and two staff are delegated as responsible for handling resident’s monies. Records and receipts are kept of all transactions. The inspector checked two of the resident’s monies against records and they were accurate. There are separate record books of charges made by the chiropodist and hairdresser, which are signed by them to confirm they have received payment. Fees are paid directly in to the homes account. The home provides staff with relevant training with regard to safe working practices. There are fire procedures in place, which are understood by the staff. The fire alarms are tested weekly and the tests are recorded. There evidence that the home maintains electrical systems and equipment. The gas boiler and central heating systems are serviced regularly to ensure that the Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 22 home is adequately heated. Thermostats are fitted to the communal baths and showers. The registered manager ensures compliance with legislation by providing policies and procedures, staff team meetings, training, and observation. A generic risk-assessment of hazards around the home has been completed. Substances harmful to health (COSHH) are stored appropriately. Accidents and injuries are reported and recorded and the home provides information to CSCI of any adverse effects to resident’s health. Little Hayes DS0000012508.V315955.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 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A No. 1. Standard OP19 Regulation 23 (C) (i) Requirement You are required to ensure that fire doors are only held open by self-closing devices approved by the fire safety officer of the local fire and rescue authority. A Risk Assessment must be undertaken in respect of the first floor windows and action taken to ensure the residents are not at risk of falling. A Risk Assessment must be undertaken in respect of the radiators and action taken to ensure that residents are not at risk of burning from the exposed radiators and pipes. Timescale for action 31/03/07 2. OP19 13 (4) (a) 30/04/07 3. OP19 13 (4) (a) 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP7 OP12 OP19 Good Practice Recommendations It would be beneficial to residents if they had the opportunity to be involved in the drawing up of and review of their care plans. The manager must ensure that care plans are reviewed monthly. It would be of benefit to residents if a number of carers were able to facilitate activities, to ensure that they go ahead as planned. It would be considered good practice to paint unpainted DS0000012508.V315955.R01.S.doc Version 5.2 Page 25 Little Hayes 5. OP29 radiator covers as they do not blend in with existing surroundings and have become stained and look unsightly. The manager may want to consider renewing the staff teams Criminal Record Bureau checks and Prevention of Vulnerable adult checks to ensure there has been no change in people’s status as fit persons to work with vulnerable adults. Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Little Hayes DS0000012508.V315955.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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