CARE HOMES FOR OLDER PEOPLE
Liverpool Road (23) 23 Liverpool Road Thornton Heath Croydon Surrey CR7 7RE Lead Inspector
Claire Taylor Unannounced Inspection 28th October 2005 1:00pm 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 Liverpool Road (23) DS0000028100.V253297.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. Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Liverpool Road (23) Address 23 Liverpool Road Thornton Heath Croydon Surrey CR7 7RE 020 8653 5280 020 8653 5280 no email 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) Mrs Daphne Mahoney Mrs Daphne Mahoney Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23 March 2005 Brief Description of the Service: Beatitudes, 23 Liverpool Road, is situated in a quiet residential area in Thornton Heath. It is near the shopping centre and well placed for transport links to local amenities and nearby Croydon town. Beatitudes is registered to provide care and accommodation for three older people and operates very much as a small family type home. Service users each have a single bedroom and adequate shared communal space, including a lounge and dining area. There are two toilets and one bathroom. There is a small rear garden with lawn and paved areas. Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over an afternoon and lasted 4 hours. Inspection time was spent talking to the residents and the manager /owner Mrs Mahoney. No other staff were on duty and so their views could not be sought on this occasion. A brief walk round the premises took place and various records were checked concerning residents’ plans of care, staff files and the home’s general administration systems. Prior to this particular inspection, the Commission did not receive any comment cards from either residents or their relatives. There have been no new admissions to the home since the last inspection. The residents and manager are thanked for their time to facilitate the inspection process. What the service does well: What has improved since the last inspection?
The owner/ manager is commended for her hard work in addressing previous requirements and recommendations. Of the nine previous requirements (Inspection March 2005) eight have been met and all five recommendations have been addressed. The statement of purpose has been revised and now includes all the necessary information that both current and prospective residents would need to know about the home and services provided. Information about how to make a complaint is now included in the Service User Guide and identifies how the complainant can contact the Commission for Social Care Inspection local office. Staff files are now more organised to show
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 6 what skills and knowledge individuals have acquired and what training is planned. Staff are now receiving regular supervision from the manager/ owner resulting in their job performance being monitored more carefully. Following some staff recruitment, there are now a total of three care staff who have completed the NVQ level 2 qualification in care meaning that the home has achieved the required target set by the National Minimum Standards. The premises were inspected by the Environmental Health Department in April of this year and findings were positive with only two recommendations set. The owner/ manager had addressed both. A new fire alarm system has been installed and the premises have been risk assessed to identify any potential hazards and action to be taken to minimise the risk of injury. This further maximises the health, safety and welfare of the residents and staff working in the home. Quality monitoring has progressed in that feedback about the home’s care practices has been sought from residents’ relatives and other professionals. What they could do better:
Some improvements are needed with risk plans for residents to further safeguard their welfare. Each risk assessment must specify the risk; possible consequences of the risk; and action required to minimise it. Risk plans must be reviewed at more regular intervals to reflect changing needs. There was limited evidence of structured recreational activities taking place indicating that residents are under stimulated. This view was reflected in comments made by residents. The home needs to provide a wider range of recreational activities that addresses the social needs of the residents and meets their needs and preferences. Records to evidence participation must be maintained in more detail. Given that the mobility needs of one resident have changed and somewhat deteriorated, the premises must be reassessed by an occupational therapist. This will ascertain whether the home can continue to meet their needs and/or determine if further adaptations or equipment are required. Residents were generally complimentary about the food provided although through discussion, it was not clear that they were always offered choices. The manager is therefore required to keep a record that shows how residents’ food choices are respected. Although the home shows vigilance in its vetting of staff, the registered provider must ensure that any future employees obtain a new and up to date CRB and POVA check before they commence work. CRB disclosures are not transferrable between employment to ensure maximum protection for vulnerable adults. Alternative arrangements for locking the front door, also a fire exit, must be put in place e.g. an electronic keypad access system. Fire doors must not be kept locked with a key as this does not comply with current fire regulations and could therefore compromise the safety of the people who live and work in the home. As an interim measure the manager must develop a risk assessment and locked door policy. The staff team and manager are now in need of fire training in order that they keep fully up to date with current legislation and observe safe fire practices. As good practice, the manager should explore ways that the home could facilitate more community based activities for the residents.
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 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. Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 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 Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 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 and 4. Standard 6 is not applicable to this home as it does not provide intermediate care. The Service User Guide and Statement of Purpose have been revised so that they accurately reflect the aims and objectives of the home, and provide full information about the services on offer. The home has its own assessment plan to ensure that any new resident’s needs are fully assessed prior to their admission and that staff are aware of how to support them. Residents’ needs have been assessed and the range of needs presented was being appropriately met. EVIDENCE: There have been no new admissions to Beatitudes since the last inspection. Residents files were examined and in very good order. Each individual has an up to date needs assessment undertaken by a care manager from his or her placing authority. The manager has also devised a pre-admission assessment tool for the home and assessments were completed appropriately for each resident when they all first moved to the home in 2003. The assessment includes general information about the person, details of their background, medical and social history and comprehensive details of specific areas such as
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 10 nutrition, skin care, medication and mobility. This therefore provides staff with a detailed profile of each individual’s needs. As previously required, the home’s Service Users Guide / Statement of Purpose has been revised and now includes all the necessary information for current and prospective service users. Written in large print with pictures included, the documents outline accurate information about the home, including the type of residents catered for, staff information and the facilities available. A summary of the complaints procedure is now included. The registered manager / owner, a trained nurse, has many years experience as a ward sister and worked as a home manager with a large company. Records showed that care staff have all had experience of working with older people in a hospital setting. Two residents have visual impairments and staff have attended training on care of the blind / partially sighted provided by the R.N.I.B. Another resident has Parkinson’s disease and staff receive training as part of the home’s induction. Additionally, literature concerning this health condition was available for staff to access. Liverpool Road (23) DS0000028100.V253297.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 and 8 The residents care and health needs are identified and reviewed regularly so that they continue to be met and they are able to access care from additional healthcare services. Effective support is provided within a risk management framework although some individual plans need further development to fully safeguard individuals from potential harm. EVIDENCE: The development of the residents’ care plans has improved further since the last inspection. Generated from each individual’s needs assessment, the desired outcome of the planned care is clearly documented. Plans set out the action that care staff must take to meet the needs of the resident and also detail their personal abilities, hobbies and interests. Personal care charts were in place for each resident and being well maintained. Care plans are reviewed on a monthly basis and any changing needs are identified and recorded. For example, records revealed that deteriorating healthcare needs concerning one resident were being appropriately monitored by the home and a review meeting had been arranged. Regular reviews of care needs thus provide the resident and relative if appropriate, with assurance that the home can continue to meet their needs.
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 12 Residents are in regular contact with General Practitioners and other health care professionals as required. I.e. chiropody, optician and one resident attends regular appointments with a neurosurgeon for his Parkinson’s disease. Nutritional needs are closely monitored and weight charts kept on file for each individual. Exercise and mobility is encouraged and measures taken to minimize the risk of falls i.e. suitable grab rails fitted and white markings on steps for service users with visual impairment. Risk assessments covering key areas such as fall prevention are in place although some improvements are needed. Risk plans need to be expanded upon and more detailed as well as reviewed more frequently to reflect any changing needs. Each risk assessment must specify the risk; possible consequences of the risk; and action required to minimise it. Records of all healthcare appointments are kept in addition to individual progress notes and an accident book. Liverpool Road (23) DS0000028100.V253297.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 and 15 Residents are provided with some opportunities for recreational and social activity although more could be done to encourage their participation in dayto-day activities and links with the local community could be improved upon. Menus show that food provided is well balanced and nutritious although the home should keep records to show that residents’ choices are respected. EVIDENCE: Residents’ preferred social and leisure interests are recorded in their care plans. The residents all attend a day centre for three to four days a week where activities such as games, sing-a long sessions and quizzes are provided. One resident said that the centre provided them with social company. Recreational activities available within the home include television, radio, gentle exercise sessions, newspapers/ magazines, and board games. Information about activities and local social events.is kept on a notice board. As previously recommended, an individual activity timetable for each resident is kept although records indicated limited evidence of recreational activities taking place. During this inspection, the residents were sitting in the lounge watching television and individuals presented as under-stimulated. This view was reflected on speaking with individuals. They felt that staff do not always have the time to engage in activities. A requirement is therefore set that the home provides a wider range of recreational activities that addresses the social needs of the residents and meets their needs and preferences. Records to
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 14 evidence the residents’ participation must continue to be maintained. In addition, the manager should explore ways that the home could facilitate more community-based activities. Residents’ religious needs and beliefs are catered for and one resident said that the home arranges transport for them to attend church every week. Residents are provided with three meals a day as well as regular snacks and drinks. A copy of the menu, supplemented with photos, is made available to residents and showed that the home offers a varied and nutritious range of meals. Residents were generally complimentary about the food provided although through discussion, it was not clear that they were always offered choices. The manager is therefore required to keep a record that shows how residents’ food choices are respected. As previously required the use of disposable plastic aprons at mealtimes has ceased and residents are provided with more suitable protective aids to eat their meals. I.e. washable napkins. Liverpool Road (23) DS0000028100.V253297.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): 16 and 18 An appropriate complaints procedure is in place to ensure that the views of residents, their families and friends are listened to and acted upon. The home’s practices generally safeguard residents although the vetting of employees must be improved to ensure that people living in the home are fully protected from abuse. EVIDENCE: Improvements have been made to the home’s complaints process since the last inspection. Information about how to make a complaint is now included in the Service User Guide and identifies how the complainant can contact the Commission for Social Care Inspection local office. A summary of the complaints procedure is available in the home for residents and other relevant parties to read. A record book is kept although the complaint log form could be slightly improved for better clarity i.e. the date; nature of complaint; outcome and action taken should be specified. There are systems in place regarding the protection of vulnerable adults and relevant policies to safeguard the residents’ welfare. E.g. management of finances, dealing with aggression and conflict and a whistle blowing policy to state what action to take should staff suspect anything untoward. Records confirmed that any new staff are properly inducted on abuse awareness and showed that the majority of staff have undertaken training in the protection of vulnerable adults. Staff files examined indicated that improvements with staff recruitment checks are needed to ensure the full protection of residents. This issue has been highlighted in further detail under staffing standards.
Liverpool Road (23) DS0000028100.V253297.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, 22 and 26 The home is well maintained and clean with a good standard of decor meaning that residents are provided with homely and pleasant surroundings in which to live. To further maximise residents’ safety and ensure that changing needs can continue to be met, a suitably trained professional should reassess the premises to check that all necessary environmental aids and adaptations are provided. EVIDENCE: The home is located on a residential street in Thornton Heath. Local shops and public transport are within easy reach of the home. The premises are decorated to a good standard and furniture and fittings appeared of good quality, safe and well maintained. Suitable aids and equipment are in place such as grab rails, walking frames as well as white markings on steps for those residents who have a visual impairment. The premises were last assessed by an occupational therapist in 2004 as suitable to meet the needs of the current resident group. Given that the mobility needs of one resident have changed and somewhat deteriorated, the premises must be reassessed to ascertain
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 17 whether the home can continue to meet their needs and if further adaptations or equipment are required. One resident has the use of a wheelchair for activities outside of the home that may involve travelling over long distances. A fire safety inspection on the premises has been carried out by the London fire and emergency planning authority since the Commission’s last visit. Records showed that the registered provider had addressed all of the requirements set including provision of an appropriate fire alarm system and fire risk assessment for the building. The home has also been inspected by the Environmental Health Department in April of this year and recommendations were seen as addressed including completion of a food hazard safety assessment. The home appeared clean and free from odour. This is a small family type home and laundry facilities are sited within the kitchen. Tasks are undertaken at suitable times to keep food preparation and laundry activities separate. Hygiene practices are well observed to ensure good infection control. Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 There is a stable staff team who have been provided with appropriate training and guidance to meet the needs of the people living there. On the whole, recruitment practices are securely managed to maximise protection for the residents although all appropriate checks must be obtained for staff before they start work. EVIDENCE: Due to the home’s small size, residents benefit from a family type environment. The registered manager / provider works most days and is available on call in the event of an emergency. Five other care staff are employed at the home and one staff sleeps in at night. Care staff and the manager also undertake ancillary duties such as cleaning and cooking. The manager explained that there are usually one to two members of staff on duty during the day depending on residents’ activities. During this inspection, the manager was working on her own due to staff sickness. Staff files sampled were well organised and mostly contained all the required documentation to evidence their fitness to work with this resident group as well as training certificates. All new staff who commence work in the home undergo a vetting procedure to ensure that they are fit to work with vulnerable adults. Since the last inspection the home has employed two new members of staff; their files contained the majority of required checks including a completed job application, the terms and conditions of their employment, two references, proof of identity and a CRB disclosure/POVA check. The CRB checks however had been completed by both staff’s previous employers and such checks are
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 19 not transferable. The manager must therefore ensure that an up to date CRB and POVA check for any future employees is obtained before they commence work. Within the first six weeks of employment, new employees complete induction training based upon principles of care, safe working practices, worker role and the experiences and needs of older people. Topics covered were found to be relevant to the home’s stated purpose and needs of the current resident group. Following recruitment the home now has three care staff who have achieved their NVQ level 2 qualification in care. This meets the required target set by the National Minimum Standards for 50 of the staff team to be trained to this level. As previously recommended, specific needs are covered as part of staff induction e.g. Parkinson’s disease and Diabetes. Other specialist training courses attended include awareness of visual impairment, nutrition course and dementia awareness. A training and development assessment and profile for each staff is also maintained. Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,36 and 38 Based on residents’ views, the home has good systems in place to show how they intend to make positive changes and monitor quality of care. Residents are benefiting from a well-supported staff team who now receive regular supervision and guidance from their manager. Generally, health and safety practices are well observed although alternative security measures for locking the front door must be put in place to ensure that residents and staff safety is not compromised in the event of a fire. Additionally staff are now in need of formal refresher training on fire safety. EVIDENCE: The manager/ owner demonstrates competency in managing a care home, has many years experience of working with elderly people and has acquired relevant skills and knowledge through training. Mrs Mahoney is fully involved with the day-to-day running of the home and staff therefore benefit from ongoing guidance and support. Improvements have been made with staff
Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 21 supervision since the last inspection. Records showed that staff receive six weekly supervision as well as a yearly appraisal with the manager. A range of quality assurance systems are used to measure the success of how the home is achieving its aims and serve the best interests of the people who live there. Due to the small size of this home, daily discussions with residents regularly take place as well as formal meetings to seek their views about the running of the home. Minutes of these meetings were available and showed that residents views form the focal point of discussions. A ‘residents satisfaction survey’ is offered on an annual basis and had been completed within the last twelve months. Feedback indicated complimentary views about the home and the care provided. The manager reported that new questionnaires were due to be offered to the residents. As previously recommended, questionnaires were offered to residents’ family members and other professionals in August of this year. Feedback was very positive. One professional remarked “excellent level of care”. Certificates showed that staff have achieved training in key health and safety topics such as food hygiene; moving and handling and first aid. Fire safety training needs to be organised for staff however which the manager acknowledged. Accurate records are kept for accident and incident reporting. Fire drills, fire equipment and hot water temperature checks were being carried out at appropriate intervals and cleaning products are stored safely. Informative risk assessments for the premises have been put in place since the last inspection that further safeguards the health, safety and welfare for all those living and working in the home. One area of concern was identified concerning health and safety for which a requirement was set. The manager explained that one resident may try to leave the premises without informing staff and as a consequence, the front door is locked with a key for safety reasons. The front door is also a fire exit however and this could compromise the residents’ safety. The provider is reminded that fire doors must not be kept locked with a key as this does not comply with current fire regulations. Alternative security measures must be put in place e.g. an electronic keypad access system. The manager is also required to complete a risk assessment and locked door policy until the necessary work has been completed. Such restrictions as locking the front door could also be construed that residents are not fully able to exercise their rights within the home and this must be included in the risk plan. Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 X 2 Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes- 1 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 12(1a)(2& 3) 13(4 & 5) Requirement Residents’ risk assessments must contain sufficient detail to specify what preventative measures or actions are in place to minimise risks. (Timescale of 30.6.05 not met) The home needs to provide a wider range of social and leisure activities that meet the needs and preferences of the residents. Records to evidence their participation must be maintained. The menus must evidence a record of food provided for service users and that their respective choices have been met. Given that the mobility needs of one resident have changed and somewhat deteriorated, the premises must be reassessed to ascertain whether the home can continue to meet their needs and/or determine if further adaptations or equipment are required.
DS0000028100.V253297.R01.S.doc Timescale for action 31/12/05 2. OP12 12(1-3)16 (2)(m&n) 31/01/06 3. OP15 17(2) sch. 4 13 30/11/05 4. OP22 14(1a) 23(2 n) 31/12/05 Liverpool Road (23) Version 5.0 Page 24 5. OP29 17(2) 19(1)(b,c) The registered provider must ensure that they obtain an up to date CRB and POVA check for new staff before they commence employment. Staff must not to work unsupervised until such time that a valid CRB and POVA clearance has been obtained. All staff must attend fire safety training. 30/11/05 6. 7. OP38 OP38 23(4 d) 31/01/06 31/01/06 23(4 b & c The front door, a designated fire iii ) exit must not be kept locked with a key and alternative security measures need to be installed such as an electronic keypad system. 13(4) Until the work has been completed as idientifed in requirement no .6 , the registered provider must write a risk assessment and policy for locking the front door. 8. OP38 30/11/05 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 OP13 Good Practice Recommendations The manager should explore ways that the home could facilitate more community based activities for the residents. The complaint log form could be slightly improved for better clarity i.e. the date; nature of complaint; outcome and action taken should be specified. 2. OP18 Liverpool Road (23) DS0000028100.V253297.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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