Inspection on 28/04/05 for Lyndhurst Residential Care Home (Orrell Lane)

This inspection was carried out on 28th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lyndhurst Residential Care Home... 09/09/08

Lyndhurst Residential Care Home... 05/11/07

Lyndhurst Residential Care Home... 16/06/06

Lyndhurst Residential Care Home... 12/01/06

Lyndhurst Residential Care Home... 28/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Havenview Care Home 51 Orrell Lane Walton Liverpool L9 8BX Lead Inspector Mr John McCabe Miss Julie E King Unannounced 28 April 2005 9:30 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 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. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Havenview Address 51 Orrell Lane Walton Liverpool L9 8BX 0151 525 2242 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Lyndhurst Limited Acting Manager Linda Elliot CRH 20 Category(ies) of OP - 20 registration, with number of places Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To accommodate one named adult under the age of 65 years in an overall total of 20 Date of last inspection 28 January 2005 Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Havenview is a small privately run home in the Orrell district of Liverpool. The home has recently been taken over by a company called Lyndhurst Limited which is a family run business with a home in Wales. The home is set in a Victorian detached property and the rooms are on two floors. The rooms are either double or single and there are enough bathrooms and toilets on both floors to meet the residents needs. The home is staffed twenty four hours a day. The double rooms are used as single at present. However the home can accommodate residents who wish to share. The home is well served by local shops and public transport and there are pubs and restaurants close by. Newspapers are delivered to the home and arrangements can be made for hairdressing and chiropody services for residents as required. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours and was undertaken because of an initial anonymous complaint about lack of care in the home regarding one of the residents. There had been no response or compliance with outstanding requirements from previous inspections. A full tour of the premises took place and staff and care records were inspected. The inspectors spoke to each of the three staff on duty plus seven of the 10 residents and two visitors. The home is registered with the Liverpool/Wirral C.S.C.I. in the name of Havenview, but is known as Lyndhurst by the local Social Services department as a result of the recent purchase of the home. The advertising board of the home, which is situated in the front garden, displays the name Lyndhurst. The actual name of the home will be clarified with the present owners and the Commission so as to accurately reflect the registration details. What the service does well: What has improved since the last inspection? There has been slight improvement in the formulation of the pre admission assessment documents and residents care plans. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5. The homes Statement of Purpose does not provide enough information for prospective residents so they can be clear about the services the home provides to meet their care needs. The lack of specialist care training for care staff may lead to unsafe care practice and could therefore compromise the safety of both residents and staff. EVIDENCE: The homes Statement of Purpose and Service User Guide needs to be updated to include the current names of staff members, and give more details of what the home can offer, e.g. lifts, wheelchair access, therapeutic diets, activities. The present document contains reference to the Welsh Commission, rather than the CSCI. Not all residents in the home have written contracts or terms and conditions of stay. Those documents that do exist did not state or confirm the room number, which the resident agreed to on signing the document. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 10 The homes pre admission assessment document has improved since the last inspection, but still contains a “Nursing Assessment”. The care home caters for personal care only, and does not offer nursing care for residents. The home has wall handrails, ramps for wheel chair access and a lift, which helps residents to access all parts of the building. Currently resident’s specialist care needs include dementia/cognitive impairment, diabetes, stroke, confusional states, and infection with Methicillin Resistant Staphylococcus Aureus (MRSA). However the home does not provide specialist care training for the staff. Specialist care training for staff is required to ensure that the assessed and changing needs of the residents can be met and now must be provided to all care staff in the home. The management of the home does encourage prospective residents to stay at the home; or to spend time at the home, possibly having meals, before they move in on a permanent basis. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11. The lack of staff training in the safe handling and administration of medications, combined with the lack of policies and procedures means that the residents are not protected. EVIDENCE: Some improvements have been made to most of the residents care documentation since the last inspection. This has resulted in the resident’s daily health records being more informative and relevant to the care needs of the resident. Personal support in the home is offered in such a way as to promote and protect the residents’ privacy, dignity and independence. Care plans contained some information as regards to the residents care needs, though more should be documented regarding risk assessments to ensure the safety of the resident. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 12 All residents in the home can access their NHS entitlements; and care staff escorts the residents to their hospital appointments. On the day of inspection, none of the residents had pressure sores. However two residents did have M.R.S.A. The community nurses attend the home twice a week and give care and guidance for these two residents. The management of medications was examined as part of the inspection, and numerous out of date medications were found stock pilled in the treatment room. The inspectors were told that there had been a problem with the new pharmacist accepting the previous pharmacy’s old medications. On the second day of this unannounced inspection all the medications not currently in use were returned to a local pharmacy, leaving only the current resident’s supply. There were no controlled drugs on the premises. Required medication policies and procedures were not available on either day of this unannounced inspection, which is a breach of regulation. Also minimal evidence of staff training regarding the safe handling and administration of medications was seen. A requirement for staff training regarding all aspects of medications was issued to the acting manager by the inspectors. During the inspection, the care staff were observed to be polite and courteous to the residents, and knocked on the bedroom doors before entering. Visitors informed the inspectors that at no time had they had concerns as to how the staff addressed the residents or how they were handled. The home has policy for the care of the dying resident, but no information on cultural and ethnic death rites. These should be included in the policy for future guidance to care staff. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15. Residents social, cultural, religious and recreational interests and needs are not being met. EVIDENCE: The residents are not being consulted to ensure they can exercise choice and control over their lives. Organised social activities for residents are not being undertaken on a daily basis in the home, this may lead to boredom, frustration and apathy amongst the residents. The meals provided, according to the residents, are good - offering both choice and variety. However the standard of cleanliness in the kitchen area was poor. On the day of the inspection no organised social activities had been planned for the residents, and there was no documentary evidence at all that any planned activities took place in the home. Access to the rear garden of the home is severely restricted because of the danger and hazards of the fallen wall, trees, debris and rubbish. This means that even in good weather the residents are restricted to the inside of the house, or the immediate patio area. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 14 Residents informed the inspectors that many days in the home, especially during winter were “very boring”, and “the days are long”. More must be done to provide meaningful opportunities for social stimulus. The home’s cook was not present at the time of the inspection. Menus were not displayed in the home, and the menu book was difficult to understand. Most residents did say they enjoyed their meals, but would like more variation for the evening meal. However one resident told the inspectors “they don’t give me enough to eat,” and another said “I’m hungry at night”. The inspectors examined the kitchen and store areas. The kitchen was dirty, with the walls, floor and ceilings all showing signs of grease and food debris. Ants were seen behind the freezer, and tiles were missing from next to the cooker. The extractor system of the main cooker was nearly blocked with dirt and grease, and parts of the floor seals were lifting. The inspectors requested an Environmental Health inspection as soon as possible after this visit. The residents are encouraged to maintain contact with their family and the wider community. However some of the residents spoken to told the inspectors that they had been moved, or had changes made to their daily routines by the management and staff, without their consent. This was discussed with the acting manager and company representative during the inspection. The need to consult fully with residents and their representatives (as appropriate) when changes to their care are being considered was reinforced. A record of such discussions should be kept on the resident’s file. One of the residents told the inspectors “I’ve not had a bath for over a month”. Another resident told the inspectors that “the staff don’t help me much” (regarding personal hygiene), and the resident concerned was unkempt in appearance and unshaven. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 standard(s) 16,17,18. The lack of progress in producing a protection vulnerable adults procedure, plus the lack of senior staff knowledge about the Protection of Vulnerable Adults (POVA) regulations undermines the management of the homes ability to sufficiently safeguard residents. EVIDENCE: The home has a complaints procedure, which is referenced to the Welsh Commission, and a complaints record. This must be amended to accurately reflect the contact details of the CSCI Liverpool area office. No internal complaints were recorded in the last year, but two complaints were received by the C.S.C.I. prior to this inspection. Both of the complaints are still under investigation by the commission. Residents did comment that they are confident that should they have concerns they will be listened to, taken seriously and acted upon. On the day of the inspection, both the homes acting manager and the administrator had no knowledge of the Protection of Vulnerable Adults (POVA) regulations. This lack of knowledge is reflected in the poor and unsafe recruitment of staff policies of the home that must be addressed as a matter of urgency. The inspectors informed the homes management that information relating to POVA could be downloaded from the Department of Health Website. This Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 16 information could then be used to develop a better understanding and knowledge amongst the staff team. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26. The standard of the furnishings and fittings is poor and potentially dangerous placing residents and visitors at risk of harm or injury. EVIDENCE: A significant amount of work is required as a matter of urgency to bring the facilities up to an acceptable level so that residents can live in safe, comfortable surroundings. Numerous resident’s rooms had a strong smell of urine, and many of the carpets in these rooms were dirty and stained. Some rooms had damage to the wallpaper, ripped borders and chunks of plaster missing off the walls. Bed rails were seen in use for some residents, but the ones seen were not fitted correctly, and no records were available regarding risk assessment and checking for these residents. The upstairs corridor also smelt strongly of urine. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 18 Some beds were against radiators, which could be a potential serious risk of burning for a resident. The acting manager was told of the risks by the inspectors when this was seen. The hot water in the first floor bathroom was too hot, but the daily check completed by the care staff showed that the temperature was just right. There was no thermometer in this bathroom, so it was not certain how the care staff were able to check the bath water temperature before bathing a resident. The resident’s bedrooms had lumpy pillows, and torn bedding was seen on some beds. The plastic mattress covers were also ripped and torn, exposing stained mattresses and bed bases. Minimal infection control policies and procedures were in place; and training for the staff regarding infection control, specifically MRSA was not evident. A bowl of dirty water was found under the kitchen sink, as there was a leak in the waste pipe. A dirty mop and bucket were also found in the kitchen store, along with a bottle of sauce that had to be thrown out due to the hard, stale sauce around the top of the bottle. The external grounds are mainly inaccessible due to the unsafe flags to the front of the building, and the rubbish, fallen trees and fallen down garden wall to the rear. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The policy and procedures for the recruitment and training of staff fail to meet the standard required. Records of staff training lack detail and do not evidence the competence of staff to do their jobs. The training needs of staff must be reviewed to ensure the health and safety of both residents and staff is promoted. EVIDENCE: Currently the home has no registered manager. An acting manager who has worked part time in the home for four years is running the home. The new owner purchased the home 6 months ago. Neither the acting manager nor the home’s administrator have an informed knowledge of the National Minimum Standards (NATIONAL MINIMUM STANDARDS), and recent legislation regarding POVA. The homes policy and procedures for recruitment of staff fails to meet the required standard. Fifty (50 ) per cent of the staff currently working in the home have no valid up to date Criminal Records Bureau (CRB) or POVA enhanced clearance certificates. This is unacceptable and must be addressed as a matter of urgency as discussed at the time of the inspection. Most of the staff personnel files did not contain two references, terms and conditions, contracts, and other required documents. The home’s application Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 20 form needs to reviewed and updated to ensure relevant information is gained from prospective employees before they are given the job at the home. The inspectors seized some of the staff personnel files and other documents from the home for further investigation by the Commission. On the day of the inspection, it was difficult for the inspectors to evidence records of staff who had undertaken training for e.g. manual handling, food hygiene, and fire drill practice. This type of training is essential for the health and safety of the residents and staff. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36,37,38. There is no leadership, guidance and direction to staff that ensures residents receive consistency of care and are safe in the home. The home does not have a quality assurance process; this results in some practices that do not promote the health, safety and welfare of the people using the service. EVIDENCE: The home does not have a quality assurance process; this results in some practices that do not promote the health, safety and welfare of the people using the service. Lyndhurst (Havenview) has an acting manager who is not experienced in care home management and a limited working knowledge of the National Minimum Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 22 Standards and Care Homes Regulations. The acting manager has yet to make application to the commission to be registered. The registered provider must appoint a suitably qualified and competent manager as soon as possible. The arrangements for accounting and managing resident’s finances are failing to safeguard residents. While residents and visitors made positive comments about the staff team; inspectors observed inconsistencies and outdated management practices, along side outdated policies and procedures. The administrator and acting manager were unable to provide evidence of the personal allowances belonging to the residents as required under regulation 17 (2) Schedule 4 (9). This must be addressed urgently. The homes quality assurance system is also lacking. Meetings and surveys for residents and staff are not held in the home, and the registered person does not provide the commission with a monthly written report on the conduct of the home as required. Visitors/relatives informed the inspector that they had never been asked as to their opinion of the care home. Inspection of records indicated that regular testing of emergency lighting; fire drills did not always take place within the home. The gas safety certificate and the NICEIC (electrical safety) certificates, along with a relevant fire risk assessment were not available. The acting manager was not able to show the inspectors the record of staff that have attended fire prevention and action training, and the emergency lighting checks were not up to date. As a result of these findings, the fire safety officer from Merseyside Fire Service was informed and a follow up visit requested as soon as practicable. Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 1 COMPLAINTS AND PROTECTION 1 2 2 2 3 2 2 1 STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 1 1 3 1 x 1 1 1 1 Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The Registered Person shall ensure that the Homes Statement of Purpose is updated and include the services and facilities provided by the home for residents. Information regarding the Welsh Commission should be exluded from the document. Previous timescale of 28th February 2005 not met. The registered person shall ensure that all residents in the home have a contract and terms and conditons of their stay in the home which must include all the points as listed under this standard. Previous timescale of the 28th Febraury 2005 not met. The registered person shall ensure that Specialist Care Training for staff is facilitated in the care home. A plan of how the training needs of staff are to be addressed must be provided within two weeks of the receipt of this report. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Timescale for action 30 May 2005. 2. 2 5 30 May 2005 3. 4, 7 & 8 19 30 May 2005. 4. 9 13 30 May 2005 Havenview Care Home Page 25 5. 12 &14 16 6. 15 16 7. 18 13 8. 19 23 medications received into the care home - and all medications that are not currently in use must be returned to the supplying pharmacist. The registered person shall ensure that organised activities for residents are faciltated in the care home, according to the choices and preferences of the resident, and these activities are documented in the residents care plans. The registered person shall provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such times as may be reasonably be required by service users. The registered person shall ensure that documention in relation to the Protection of Vunerable Adults is available in the care home. All staff must be informed of the the policy and undertake relevant documented training. The registered person shall ensure that the premises to be used as the care home are well maintained at all times both internally and externally. The Registered person must(1) Replace all the floor coverings throughout the care home (2) Replace all wall coverings throughout the care home (3) Repair all damaged walls in residents bedrooms (4) Replace all bedding, to include sheets, pillows, mattress protectors, bed covers and towels (5) Replace of repair all items of F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 30 May 2005 Immediate and ongoing 30 May 2005 13 May 2005. Havenview Care Home Page 26 9. 20 23 10. 21 13 11. 16 23 damaged furniture throughout the home (6) Repair all damage to, and deep clean all bathrooms and toileting facilities (7) Repair or replace all broken curtain rails/poles and curtains (8) Make safe, in accordance with Environemental Health requirements, the external grounds to the front, side and rear of the care home (9) Dispose of all rubbish and waste fron outside the building, and ensure that in future all waste is stored safely and securely. The registered person should produce an action plan stating when all these items will be addressed within two weeks of receiving this report. The registered person must confirm in writing when each item has been complied with. The registered person shall ensure that all equipment provided at the care home is maintained in good order The registered operson must obtain safety certificates for all moving and handling equipment and the gas and electrical safety certificates and forward copies of these to the CSCI without delay. The registered person shall ensure that adequate risk assessments are completed and appropriate action is taken on their findings - specifically there must be risk assessments in place about the use of bed rails and the risks of scalding from hot surfaces such as radiators, and hot water immersion facilites. The registered person shall F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 30 May 2005 30 May 2005 30 May Page 27 Havenview Care Home 12. 8 31 13. 10 31 14. 26 16 15. 29 19 16. 28 & 30 18 17. 31 9 ensure that suitable adaptations are made, and such support, equipment and facilities are provided to service users; and all equipment is maintained in good working order at all times. The registered person must appoint a suitably qualified and competant manager to manage th care home. The registered person must carry on or manager the care home with sufficient care, competance and skill. The registered person shall after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home, and must keep the care home clean and odour free at all times. The registered person must also deep clean and repair the kitchen, in line with Environmental Health requirements The registered person shall ensure that all staff recruited to the care home have up to date and valid CRB/POVA enhanced certificate, before being employed in the care home. Previous timescale of February 2005 not met The registered person shall ensure that training programmes for staff are provided in the care home to ensure the health and safety of both residents and staff. As referred to above a plan must be submitted within two weeks of this report identifying how this will be met. The registered person shall ensure the the homes acting F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 2005 30 May 2005 30 May 2005 30 May 2005 Immediate. 30 May 2005. Ongoing to be Page 28 Havenview Care Home 18. 33 26 19. 33 24/24 20. 36 18 21. 36 18 22. 38 23 23. 38 23 24. 35 17 Schedule manager is given training in the management of a care home, and is competent in understanding the National Minimum Standards and Care Home Regulations. The registered person shall ensure that a monthly written report on the conduct of the home is forwarded to the Liverpool/Wirral office of the C.S.C.I. Previous timescale of the 28th February 2005 not met. The registered person shall ensure that meetings for residents and staff are held in the home on a regular basis. The meetings should be minuted and actioned. The registered person shall ensure that documented supervisions for staff are held six times per year. Previous time scale of 28th february 2005 not met. The registered person must ensure that all staff complete a recognised induction on commencement of employment and records of this are kept. The registered person shall make adequate arrangements for the maintenance of all fire equipment Evidence of all fire equipment safety checks must be provided to the CSCI The registered person shall make suitable arrangements for persons working at the care home to recieve suitable training in fire prevention, and the procedure to be followed in case of fire, including the procedure for evacuation and saving life. The registered person shall manage all service users monies Version 1.30 completed by 30 June 2005. 30 May 2005 30 May 2005. 30 May 2005 30 May 2005. 30 May 2005 30 May 2005 30 May 2005 Page 29 Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc 4 25. 37 17 in accordance with this regulation - Clear records of documentation regarding service users personal allowances must be maintained at the home and be available for inspection. The registered person shall keep at the care home the documents and records as specified in Schedules 1, 2, 3 & 4 of The Care Homes Regulations 2001 (ammended 2004). 30 May 2005 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 8 Good Practice Recommendations It is recommended that photgraphic and skin mapping evidence of pressure sores be documented in the care home. The community nurse should be involved with these protocols. It is recommended that cultural and ethnic death rites be included in the homes policy for this standard. It is recommended that the daily menus for residents be displayed in the care home. It is recommended that the homes infection control policy includes up to date information on the prevention and spread Methicillin Resistant Staphylococcus Aurues (MRSA) and Hepatitis B. It is recommended that all significant conversations regarding service users choices are clearly documeted. It is recommended that the homes health and safety policy is updated in accordance with current good practice guidelines. It is recommended that the water storage facility is tested for Legionella bacteria at least once a year. 2. 3. 4. 11 15 26 5. 6. 7. 14 38 26 Havenview Care Home F52_F02_S62401_Havenview_v224130_280405_Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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