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Inspection on 08/07/08 for Mavesyn Ridware House

Also see our care home review for Mavesyn Ridware House for more information

This inspection was carried out on 8th July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People living at this home tell us they are happy and well cared for. They said "the staff are very nice and the room I have is comfortable". The staff working at this home are pleasant and understand the needs of the people living there. The home is pleasantly decorated and feels very welcoming.

What has improved since the last inspection?

Since the last inspection the home has replaced some of the windows. It has also refurbished one of the bathrooms on the ground floor to make a more accessible wet room. The manager told us "the residents like using this and it is easier for staff to help people".

CARE HOMES FOR OLDER PEOPLE Mavesyn Ridware House Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB Lead Inspector Mandy Beck Key Unannounced Inspection 8th July 2008 09:00 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 Mavesyn Ridware House DS0000004978.V367908.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. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mavesyn Ridware House Address Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB 01543 490585 F/P 01543 490585 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) Mavesyn Ridware Residential Home Ltd Mrs Sandra Margaret Black Care Home 21 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (8) Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2007 Brief Description of the Service: Mavesyn Ridware is located off a public transport route near to Armitage and Handsacre. It provides care and accommodation to 21 older people. The home is registered to accommodate six people who have dementia care needs, and eight may have a physical disability. The home stands in its own grounds with stunning views, the gardens are well maintained and offer appropriate seating areas for the people who use the service. Mavesyn Ridware has a large lounge, conservatory and separate dining room. Bedrooms are single occupancy and some have an en-suite facility. The current range of fees are not included in the Service User Guide. People are advised to contact the home directly for this information. The most recent inspection report is available from the home upon request. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use this service experience poor quality outcomes. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • We also spent time talking to the people who use the service and to the staff who support them. • We looked at the care of two people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs. What the service does well: What has improved since the last inspection? Since the last inspection the home has replaced some of the windows. It has also refurbished one of the bathrooms on the ground floor to make a more accessible wet room. The manager told us “the residents like using this and it is easier for staff to help people”. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 7 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 Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 8 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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have basic information about the home made available to them when making a choice about living there. People’s needs are assessed before they move in. EVIDENCE: The Statement of Purpose and Service User Guide are located in the reception. People are not given an individual copy of these documents. The manager did tell us that people could have their own copy upon request. We have recommended the Service User Guide should include details of the range of fees people would be expected to pay for residency. We looked at the care records of two people living at the home as part of our case tracking process. It was pleasing to see that both people had a comprehensive needs assessment from the placing council. The home also completes their own assessment. The manager also told us that people who Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 9 are considering moving into the home are also given the opportunity to discuss their wishes during this time. People are also encouraged to spend a day at the home before they make the decision about moving in. The home does not provide intermediate care facilities. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. People using this service do receive the healthcare they require however, improvements are needed to the medication systems to make sure the risks to people are reduced. EVIDENCE: Each person living in the home has their needs assessed. We looked at two people’s care plans and found that although some of the information about healthcare needs had been recorded, there were no clear guidelines for staff to follow. This could mean that people do not receive the care they want, in the way they choose. We saw in one person’s care plan staff had written “to keep a check on XX’s weight, check diet and weight, record changes and act if necessary”. What was not included in the care plan was the person’s weight, the frequency they should be weighed i.e. monthly or weekly and what to do should weight changes be recorded. The manager also told us the weighing scales the home use are not that effective because they do not record accurate reading as the flooring of the home is uneven. She said “we do have other Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 11 scales but we have to wait for them to be bought to the home by the owner and this isn’t done every month”. We recommended the home should have their own scales that are capable of accurately recording people’s weight and allow the home to monitor people’s weight effectively. The home completes some risk assessments for each person, for example moving and handling and nutritional screening. The manager must make sure they are reviewed each month and clearly recorded. This will allow the home to keep people’s care under regular review and for them to take appropriate action if changes occur. The home is supported by the district nursing service who provide the home with pressure relieving equipment and bed rails where needed. People have access to their own doctor and other healthcare professionals as they need them. They said “if I am ill they are very good at getting the doctor out for me”. We looked at the way the home manages medicines on behalf of the people living there. There must be improvements made so that people living here are not placed at risk by potentially poor practice. During our last visit we made several requirements in order to improve the current system of medication administration and storage. They have not been met. There are still no records of the fridge temperature being taken. This means that medication that requires cold storage may not be stored safely. The manager told us “the fridge really needs replacing but we only have anti biotics about once a month”. We saw evidence of pre-dispensed medication in the medication trolley; the medicine pot contained tablets and had a strip of tape across the top with a residents name on it. Leaving medication like this increases the risk of drug errors and must cease. We conducted small audits of some people’s medication and found that in some cases medication had been signed for as given but the amount of tablets left in the box did not support this. We found medication in the trolley and storage cupboard that was no longer prescribed for people and should have been returned to the pharmacy. This was also an issue at the previous inspection and must now be actioned. The home has improved the way in which it records and keeps controlled drugs. We did however find one discrepancy with recording with a Butrans patch and have asked the manager to deal with this. We have made further recommendations and requirements to improve medication practices at the end of this report. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. People living in this home are at risk of being bored because of a lack of activity for them to take part in. The home needs to make improvements so that people using this service are engaged. EVIDENCE: During our last visit to the home people told us they were bored and felt that more could be done to improve the amount of activity that was on offer. Since then very little has changed. People said “I can watch the television when I want, I have one in my room”, another person said “they do try we went on a trip to the zoo last week it was very good and such a nice change from being indoors”. We spoke to staff and asked them how they felt they kept people active. They told us “we don’t really, we try but they don’t want to take part”, and “we could do more but we never get round to it”. “We have got some jigsaws and dominoes and we have mobility Monday people like that”. The manager told us that people can be difficult to motivate and don’t want to take part. However it is clear that people do like some of the activities on offer and we have recommended that people be consulted again about how they would like to spend their time. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 13 People living in this home are encouraged to have visitors whenever they want. They have the choice of meeting visitors in the communal lounges or the privacy of their own rooms. Although in one of the smaller communal lounges visitors can obscure to view of the television and should be aware of this when visiting. Meals are satisfactory but could be improved. People said “they’re not bad, not much of a choice but not bad”. Some of the staff commented “there isn’t much of choice everyone gets the same at dinnertime, no alternatives”. The manager added, “if people don’t like what’s on the menu we can usually offer them something else”. Teatime meals are repetitive and usually consist of soup and sandwiches. The home has told us in the AQAA they plan to discuss with people what their favourite meals are and introduce them to the home menus. We have recommended that this happens and the results are recorded so the home has a clear record of who has requested what and how they plan to include it in the menu planning. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. People using this service will have their views listened to but there must be an improvement in safeguarding systems to make sure that people are not placed at risk and staff do not take safeguarding matters into their own hands. EVIDENCE: The home has a complaints procedure but it does need to be updated. At present it does not include our contact details or the local council. People need to be aware that they can make complaints about the service they receive to other agencies as well as the home itself. There have been no complaints since the last inspection. The manager told us “we try hard to sort issues out before they become complaints”. When we spoke to people who live they said, “I have no complaints but I do know who to talk to if I needed to”. The AQAA tells us the home has updated the Safeguarding vulnerable adults policies and they have been discussed in staff meetings. The manager told us that this has not happened. Staff meetings are not being held regularly and there are no minutes being recorded. We spoke to staff about safeguarding and their role in keeping people safe from harm. None of the staff we spoke to or who responded to our questionnaire said they had received training in this area. They were unable to recall the different types of abuse or had any Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 15 knowledge of the local council guidance for safeguarding adults. We have recommended that training be sought promptly for all staff, including night staff. This will mean that people are being protected by staff that are aware of the signs of abuse, the different types of abuse and how to respond should an allegation be made to them or they witness an incident. We have also recommended the home obtains a copy of the local council guidance and updates their own policies to give staff very clear guidance should an incident occur. It was pleasing to see that since our last visit the home has introduced bed rail risk assessments for those people who need this type of restraint. The manager must however make sure that people’s need for bed rails kept under regular review. Mavesyn Ridware House DS0000004978.V367908.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 adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely and relaxing environment but more improvements are needed to make sure that safety records are kept up to date and not placing people at risk EVIDENCE: The home is relaxing and spacious. The manager told us that recent improvements have included new windows, and a completely refurbished bathroom on the ground floor. It is now being used as a wet room and people have said that it is a great improvement. The exit into the garden from the dining room has now been made more accessible with the ramp but handrails are still awaited. Once in place this will add further safeguards for people and reduce the risk of falls to people living in the home. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 17 There are some infection control practices in place and staff have available to them gloves and aprons for when they are helping people with personal care. each toilet and bathroom has liquid soap and paper towels for people to use for hand washing purposes. The laundry facilities are small but appear to serve the home well. The floor and walls need to re-coated so that they provide an impermeable and easy clean surface. This will help reduce the risks of cross infection to the people who live there. Mavesyn Ridware House DS0000004978.V367908.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 adequate. This judgement has been made using available evidence including a visit to this service. People are supported by a stable staff group but staffing levels must be kept under review so that people can be supported to take part in more activities. Staff are recruited safely and this helps prevent unsuitable people from working with vulnerable adults. EVIDENCE: There are three staff on duty during the morning and afternoon and two staff at night. Staff told us “at the moment we are ok but the staff numbers have been down because of sickness and holidays”, another person commented “I think if we had just one more person on duty we could do more with the residents”. People living in the home said “sometimes you have to wait a bit for them to come but they are very nice”. We looked at the training records for some of the staff and the home’s training matrix. Both of them showed that there were gaps in training for all staff, particularly night staff. The manager told us “I don’t sort this out, I do request that training happens but this has to be arranged by the management team”, staff also said “we know that the manager asks for training but none ever seems to happen”. This was an issue raised at the home’s last inspection. Staff need to have regular training to make sure they are practising safely and in line with current best practice and changes in legislation. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 19 We looked at the recruitment file for the only new worker to be employed since the last inspection. The file had most of the required information and importantly the security checks against the Protection of Vulnerable Adults list (PoVA) and a Criminal Record Bureau (CRB) disclosure. These checks along with other safeguards such as written references will help the home make sure that unsuitable people are prevented from working with vulnerable adults. The induction process for new staff needs to be updated so that it meets with the guidance from Skills for Care’s common induction standards. This will help make sure that staff have the introduction to social care they need. Mavesyn Ridware House DS0000004978.V367908.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 poor. This judgement has been made using available evidence including a visit to this service. The management of this home must improve in order to both protect and promote the interests of the people living there. EVIDENCE: The manager of this home is Mrs Sandra Black who has been in post as registered manager for just over four years. Staff we spoke to and who responded to our surveys said “we do get support from the manager, she tries very hard to get us the training we need”. The manager told us “I am still learning”. Mrs Black is currently in the process of completing her Registered Manager’s Award, this award is designed to give people an understanding of the role of the manager and give them the skills to manage. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 21 The manager told us that she was aware of some of the shortfalls in the home, she sees her main responsibility as making sure the care is given and care documentation is up to date. Managing other aspects of the homes running is overseen by the registered providers. We found that an improvement in all aspects of the home’s management is required if people’s safety and their wellbeing is to be maintained. Training and supervision of staff is inconsistent. Staff said “I think the manager struggles to get the training we want she does keep asking though”. Despite the AQAA telling us that policies and procedures within the home have been updated, when we checked we found that some of information held within them was out of date, there was no date for review for each policy and it was unclear who had reviewed them. Staff have told us they knew where policies were but didn’t always know what was in them. A lack of staff training has been a persistent issue for staff in this home. The training matrix we looked at had significant gaps and showed that night staff especially are not being included in required training. A lack of staff knowledge and understanding could be placing the people in this home at risk because staff may not be following current best practice guidance. The quality assurance system was discussed with the manager; she told us that she is not responsible for completing this. She also told us that no new surveys have been sent out to the people living in the home since the last inspection. We, the commission also sent individually addressed surveys to people living in the home but we have received no responses. The manager told us “they probably didn’t get handed out”. In her absence this wasn’t done. The AQAA tells us that regular audits are being completed, specifically on care planning, medication and the environment, but none were available during this inspection. It is also concerning that if medication audits were being completed regularly the issues we have found with medication during this inspection have not been identified as shortfalls as part of the audit trail. The home must improve this process so that it can demonstrate how it is operating in the best interests of the people living here. The home manages people’s money for them. Each person is given a letter when they move into the home asking that they keep no more that £4 cash with them and to give other money to the manager for safekeeping. We discussed this with the manager who told us that money can be kept in a safe, there are two signatures for each transaction and clear records are kept. In spite of these safeguards being in place the home should be encouraging people to manage and keep their own money. We have recommended the home review this arrangement by consulting with people who live here and acting upon their wishes in relation to the safekeeping of their own money. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 22 We also found required safety certificates were unavailable for inspection; we were unable to determine if the home is safe for people to live in. The manger did tell us “I can get into the office but I wouldn’t know where it’s all kept”. The AQAA gave us some of the information we needed but not all of it. For instance we are unable to determine if the fire equipment has been checked in the last year, the heating system in the home was checked in 2007 but no date is given this means we cannot see when it is due for another check. We also looked at fire equipment checks such as the emergency lighting and alarms. There were some records of fire training for some of the staff but there were no records of staff undertaking a fire drill. We also asked the manager about the recommendations from the recent fire officer’s visit. She was unable to tell us if these recommendations have been met. This will need to be done promptly so that we can feel assured people living in this home are not being place at increased risk. Mavesyn Ridware House DS0000004978.V367908.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 2 Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement People’s care plan must include clear guidelines for staff so that people’s needs are known, understood and carried out by staff. People’s plans must be kept under regular review. People’s weight must be kept under regular review with clear records kept. Care plans should clearly indicate the frequency with which this should happen. for example; monthly or weekly A record of the maximum and minimum temperature of medication stored in the fridge must be recorded. (previous timescale of 07/08/07 not met) People who use the service and administer their own medication must complete an assessment and consent form. This is to ensure everyone’s safety and understanding. (previous timescale of 07/08/07 not met) Timescale for action 01/09/08 2 OP8 13(4) 01/09/08 3 OP9 13(2) 08/07/08 4 OP9 13(2) 08/07/08 Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 25 5 OP9 6 OP9 7 OP38 The commission must be notified of medication errors or discprancies in people’s medication. 13(2) Medication not taken by residents must not be kept in a medicine pot in the trolley. They must be disposed of to reduce the risk of drug error to people. 13 (4) (c ) The home must be able to demonstrate that it is a safe place for people to live and that safety records are kept up to date. This includes fire fighting equipment, fire drills, five year electrical certificate and gas landlords. 37 08/07/08 08/07/08 01/09/08 8 OP38 18 The home must also make sure that these documents are available for inspection. Staff must have required training 01/10/08 to perform their duties, this includes infection control, food hygiene, first aid and fire safety 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 OP1 Good Practice Recommendations The home should develop a more user friendly Statement of Purpose and Service User Guide to assist people who use the service with complex needs, including sensory impairments. The service user guide should also include the range of fees that people are expected to pay for residency in the home. The home should have weighing scales that are in working order and able to accurately record people’s weight. Handwritten MAR sheets should be signed by two people DS0000004978.V367908.R01.S.doc Version 5.2 Page 26 2 3 OP8 OP9 Mavesyn Ridware House 4 5 OP9 OP9 to reduce the risk of errors occurring. It is recommended the manager completes monthly audits of medication so that discrepancies can be identified and addressed. The temperature of the medical stock room should be considered because some medications may be being stored at too high a level. The home should return unused medication as soon as possible to eliminate excess stock. The home should consult the people living there about their wishes in relation to activity provision. This should be clearly recorded so that the home can demonstrate who it has acted upon people’s wishes. The manager and staff should explore further how they can enable the people using the service to make choices within their daily lives, including meals. People in the home should be consulted about the contents of the home menus and their preferences be recorded. The home should update the current complaints procedure and make it more widely available to the people living in the home. The home needs to make sure that all staff are aware of different types of abuse and the actions they should take if an allegation is made to them. This should be done through training and staff meetings. The home should obtain a copy of the local authority’s guidance for safeguarding and make sure that all staff are aware of its content. The must make sure that the safeguarding policy is available for staff to access. The home should re coat the laundry walls and flooring so that they can be cleaned easily. New employees should be supported through an induction that meets the Skills for Care Common Induction Standards. The manager should have regular supervision and support in order to move this service forward. The home needs to develop the quality assurance system so that all aspects of practice can be audited for peoples benefit and to ensure the service is being run in people’s best interests. The home should consider how they can support people to DS0000004978.V367908.R01.S.doc Version 5.2 Page 27 6 7 OP9 OP12 8 OP14 9 OP15 10 11 OP16 OP18 12 13 14 15 16 17 OP18 OP18 OP26 OP29 OP31 OP33 18 OP35 Mavesyn Ridware House 19 OP38 manage their money more effectively. The manager should liaise with the fire officer to ensure the risk assessments around evacuation for the people who use the service are suitable. The home must also be able to demonstrate how it has addressed the requirements of the fire officers visit to the home in February 2008. Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Mavesyn Ridware House DS0000004978.V367908.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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