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Inspection on 26/04/05 for Melrose Residential Home

Also see our care home review for Melrose Residential Home for more information

This inspection was carried out on 26th April 2005.

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

Melrose is a homely type care home. There was a relaxed and friendly feel when you walk through the doors and staff were very helpful. Residents said that the staff looked after them very well.One family member said that her Mum was always looked after. Staff were very committed to looking after the residents and worked extra hours to make sure that this happened. Residents were well cared for and had good relationships with the staff.

What has improved since the last inspection?

The home had purchased two new washing machines and one dryer. One of the ovens has been replaced. Some of the residents` rooms had been redecorated and new carpet fitted.

What the care home could do better:

Some improvements in the environment had been made but progress was not at a pace to improve the standard of living of people at the home. The home, and the equipment must be adequately maintained and serviced. The homes assessment and care planning process must be improved to ensure the needs of residents are identified and met. The registered person must improve communication with the manager and staff. Difficulties with recruiting newstaff must be sorted out to reduce the pressure on current staff members. A comprehensive training programme must be put in place to ensure that staff are competent to care for the people living at home.

CARE HOMES FOR OLDER PEOPLE Melrose Residential Home 50 Moss Lane Leyland Lancashire PR5 2SH Lead Inspector Sue Hale Unannounced 26 April 2005 08:30 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. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Melrose Residential Home Address 50 Moss Lane Leyland Lancashire PR5 2SH 01772 434638 01772 434638 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) Mrs Amina Makda Mrs Janet Lesley Turner Care Home 26 Category(ies) of OP - Old age (26) registration, with number of places Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A hot water supply must be provided to service users rooms at all times. Work must be completed by 7 June 2003. The reason for this condition was several bedrooms in the home do not have constant supply of hot water. Date of last inspection 12 October 2004 Brief Description of the Service: Melrose is a care home providing personal care and accommodation for up to 26 older people. Nursing care is not provided by the home and the district nursing team undertakes any nursing intervention needed. At the time of inspection 16 he service users were living at the home.Melrose is privately owned and is situated close to the town centre of Leyland with all the local amenities. The home provided accommodation on three floors in both shared and single rooms. The majority of the shared rooms had a single occupant. One single room had an en-suite facility. The communal areas were situated on the ground floors and the home had a passenger lift and stair lift.The grounds to the house are small but adequate for the service users to enjoy. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days. Information regarding standards not assessed at this inspection can be located in the previous inspection report. The information contained in this report was gathered by discussion with the registered person, interviews and informal discussion with staff, discussion with residents and relatives. A number of records and documents were examined as part of the inspection process. A tour of the premises was undertaken. What the service does well: What has improved since the last inspection? What they could do better: Some improvements in the environment had been made but progress was not at a pace to improve the standard of living of people at the home. The home, and the equipment must be adequately maintained and serviced. The homes assessment and care planning process must be improved to ensure the needs of residents are identified and met. The registered person must improve communication with the manager and staff. Difficulties with recruiting new Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 6 staff must be sorted out to reduce the pressure on current staff members. A comprehensive training programme must be put in place to ensure that staff are competent to care for the people living at home. 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. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,34 The admission procedure was limited. Some residents had been admitted that had specific care needs that the registered person had not given staff appropriate support to meet. EVIDENCE: There were no terms and conditions of residency on the residents files checked. A blank copy of the document was not available. Individual care records were kept for all residents. The assessment document was limited. Information the home needed to decide if they could look after the residents was not completed until after they had moved into the home. The home had not obtained the care plans and assessment undertaken by Social Services. Many of the residents spoken to were very confused, they did not know that the home kept records about them and did not know what a care plan was. Staff spoken to were aware of residents basic care needs but did not have access to formal training or reference material about conditions related to old age and dementia. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 9 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) 7,8,9,11 Limited progress has been made since the last inspection on improving arrangements to ensure that the health and social care needs of residents are identified and met. EVIDENCE: Individual records were kept for all residents with a plan of care, with some instructions for staff on the action needed to be taken to meet the health and personal care needs of the residents. A resident was observed to have care needs that had not been addressed on their care plan. The plans were basic and did not include social care needs. Residents and relatives spoken to confirmed that social needs were not addressed. Discussion with staff suggested that care needs were being addressed even though there was a lack of clear plans and guidance. This approach is dependent on staff skills and experience. The staff spoken to said that pressure of work meant that social needs of residents were not being met. Risk assessments for pressure care were in place and up-to-date. Risk assessments in relation to falls were not undertaken. Records contained no Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 10 evidence of the involvement of residents and relatives in care planning or review, a resident spoken to was unaware of what a care plan was and that staff wrote down things about her. The majority of the residents spoken to were confused and would be unable to understand care planning or review. Senior carers administer medication and have had recent formal training. Records relating to the administration of medication were generally satisfactory. Permission must be sought from residents GPs is in relation to the administration of homely remedies. A healthcare professional spoken to said that referrals received were appropriate and that staff carried out instructions as necessary. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 11 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 The range of social activity within and outside the home was extremely limited, so the expectations and social needs of residents at the home were not met. EVIDENCE: There was no planned programme of activities and no one was specially employed to organise and provide recreational and social activities. A relative spoken to, said, ‘there is no stimulation, and nothing to occupy residents. I would welcome activities and trips. I take Mum out because she gets stiff just sitting, and theres no exercise available in the home’. A resident said, ‘if I could change anything. Id like more entertainment, and Id like to go on trips’. There was no allocated activities budget and no activities equipment was available. A resident spoken to said ‘I dont like TV on in the day, so I stay in my room and read newspapers’. Residents’ religious denomination was recorded on admission. Spiritual support was available if residents wanted this. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 12 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 The home had a complaints policy and procedure that required minor revision. Residents were not clear who was in charge of the home in the managers absence so did not know who to complain to. EVIDENCE: There was a complaints policy and procedure in place in the home this was displayed in the conservatory. The information displayed differed from the information given in the service user guide. The home had not received any complaints since the last inspection. A resident spoken to said, if I had a complaint I would report it. Were well looked after, so Ive no complaints. Some of the residents were unaware of who was in charge of the home on the day of the inspection as the manager was on sick leave. A resident spoken to said she would have told the manager if she had any complaints when she was there,’ but now I dont know whos in charge’. Some staff spoken to were unaware of the complaints policy and procedure and would be unable to give the correct information to residents or relatives. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 13 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) 19,21,24,25,26 Some improvements to the décor have been made but progress has been slow since the last inspection. The environment must be improved to provide residents with an adequate standard of living. EVIDENCE: Since the last inspection some resident’s bedrooms have been redecorated and new carpets fitted. A number of other areas still require attention including carpets that were stained and worn, double glazing units that have failed, outside guttering that was broken, some lampshades were missing, curtains were ill fitting or missing in some cases. The wallpaper in one resident’s room was held together with sellotape. Uneven flooring in a resident’s room had been reported to the registered person in January 2005, but no action had been taken. The registered person said that carpets were cleaned on a regular basis, but residents and staff said that this did not happen. A resident said ‘my room could be cleaner, the Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 14 carpet isn’t cleaned’. Three residents rooms and one toilet smelt strongly of urine. Residents were able to bring personal possessions within the space constraints of their room. A condition of registration of the home (made in 2003) was that hot water should be available in all residents’ rooms. This work has not been carried out and hot water was not available in several residents’ rooms so staff have to carry hot water in jugs from other residents rooms. Residents did not have a key to their private room; they had a lockable space within their room for valuables. Radiators throughout the home were guarded, but required painting. The registered person was unaware of the risks presented from incorrect water storage in relation to legionella. Two new washing machines and one drier had been installed since the last inspection. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 15 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 procedures for the recruitment of staff were inadequate and did not safeguard service users. Staff were under considerable pressure to work additional hours to cover vacant posts. The training programme was inadequate. EVIDENCE: Staff rotas were in place, which showed the number of staff on duty, but not the capacity in which they were employed. The staffing levels were in accordance with the minimum requirements of the previous regulatory bodies. However, the dependency needs of people living at the home should be reviewed and evaluated regularly and staffing levels determined accordingly. All the senior staff were aged 21 or over. Seventeen per cent of staff had qualified to NVQ two or above. The home had two full-time vacancies for carers and was having difficulty in recruiting staff. They had three regular members of bank staff, and all members of staff were working additional hours to cover the vacant posts. A health-care professionals spoken to said that staff were well organised and calm and communicated well with medical professionals. The staff records checked showed that the recruitment procedure was poor. The application form, required revision and should be specific to the home. To Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 16 ensure the protection of service users new staff must not be employed at the home unless a satisfactory POVA First or CRB check has been received. Staff spoken to had not been given terms and conditions of their employment. The induction programme was very limited and completed on the first day of employment. There was no formal foundation training. None of the staff employed at the home had up-to-date qualifications in first aid, moving and handling, food hygiene, and health and safety. A senior member of staff, said some training was available, but was not taken up by staff due to the pressure on them to work extra hours to cover vacant posts. People living at the home said about the staff ‘ theyre very good in here and staff worked very hard to ensure that residents care needs were met. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 17 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) 31,36,37,38 The home was not being managed properly, and there was no guidance and direction to staff from the registered person. This results in some practices that do not promote or safeguard the health, safety and welfare of the people living at the home. EVIDENCE: The registered manager had been absent from the home for several weeks, the registered person had not informed CSCI. The registered manager had registered to complete the NVQ level 4 management qualification. A senior carer was managing the home. Staff spoken to said that they had good support from the registered manager and the current acting manager but that communication with the registered person was infrequent and poor. Staff did not receive formal supervision. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 18 Staff identified maintenance issues that required attention by the registered person, but these have not being attended to since October 2004 The home did not have an accident book on the day of the inspection. The registered manager and acting manager did not have the authority to order supplies, and the registered person supplies only one at a time. Accident forms were not completed correctly. None of the staff had current certificates in mandatory training. Certificates to confirm that equipment had been serviced were not all up-to-date. Records indicated that fire drills, water temperature checks, call system checks were not up-to-date. A security assessment of the premises had not been done. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 19 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 x 1 2 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x 2 x x 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 1 x x x x 1 2 2 Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 20 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 OP 3 Regulation 14(1)(a) Requirement Timescale for action 30/6/05 2. OP 3 3. OP 3 4. OP 3 5. OP 7 6. OP 7 The registered person shall not provide accomodation at the home unless the residents needs have been fully assessed, and can be met. 14(1)(b) The registered person must ensure that a copy of the assessment and care plan is obtained from the funding authority for those residents funded via care management arrangements. 14(1)(d) The registered person must ensure that prospective residents are informed in writing if the home is able/not able to meet their care needs, if a place is to be offered at the home. 18(1)(a)(c The registered person must ) ensure staff are offered appropriate training in the conditons of old age, particulary dementia. 13(4)( c ) The registered person must ensure that risk assessments in relation to falls are undertaken on admission and regularly thereafter. 15(1)(2)( The registered person must a)( c ) ensure that consultation with the residents and their F57 F08 S39455 Melrose V223835 260405 Stage 4.doc 30/6/05 30/6/05 30/7/05 30/6/05 30/7/05 Melrose Residential Home Version 1.30 Page 21 7. 8. OP 7 OP 8 15 (1) 13(4) 9. OP 8 13 (1) (B) 10. OP 12 16(2)(M) (n) 11. 12. OP 19 OP 19 23(2) (J) 23(2) (B) 13. OP 24 23(2)(B)( D) 13(3) 14. OP 26, OP 38 OP 26 OP 26, OP 38 15. 16. 16(2)(K) 13(3) relatives/representatives, takes place for care planning and review. Care plans must contain clear instructions to staff as to how dentified needs are to be met. The risks associated with the use of bed rails, must be properly assessed and appropriately documented. The registered person must ensure that professional advice in relation to the promotion of continence is sought The registered person must ensure that appropriate activities are arranged within and outside the home. The resident should be consulted with regard to their preferences. The registered person must ensure that hot water is supplied in all residents rooms. The registered person must ensure that maintenance work that presents a risk to residents is carried out as soon as practicable. The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. The registered person must provide evidence that solutions are in place to control the risk of legionella. The registered person must ensure that the home is free from offensive odours. The registered person shall make suitable arrangements to prevent infection in the home. The infection control policy must be revised and all staff made aware of infection control procedures. (Timescale 31 January 2004 not met) 30/6/05 30/6/05 30/7/05 30/7/05 30/6/05 30/7 /05 30/8/05 30/7/05 30/6 /05 30/7/05 Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 22 17. 18. OP 26 OP 29 13(3) 19, scheduled 2 19. OP 9 13(2) 20. OP 30 18 (1) 21. 22. OP 31 OP 31 21 39(a) 23. OP 33 26 24. OP 36 18(2) 25. OP 37 15 (1) (2) The registered person must ensure that the laundry floor is in permeable. The registered person must ensure that information and documentation listed in schedule 2 of the Care Home Regulations 2001, in respect of persons working in a care home must be obtained. (Timescale 31st of December 2004 not met). Homely remedies must only be administered according to written guidelines. Permission must be sought from residents GP. (Timescale 30th of June 2004 not met). The registered person must ensure that all staff are suitably qualified and competent and receive training appropriate to the work they are to perform. The registered person must ensure that staff views as to the conduct of the home of sought. The registered person must give notice in writing to the Commission for Social Care Inspection, if the registered manager is absent. The registered person must visit the care home at least once a month. The visit must be recorded in line with the information detailed in regulation 26 of the Care Home Regulations 2001. A written report must be sent to the Commission for Social Care Inspection. The registered person must ensure that persons working at home are appropriately supervised. The registered person must ensure that residents are made aware of their rights to see information held about them by 30/7/05 30/6 /05 30/6/05 30/8/05 30/8/05 30/6/05 30/6/05 30/7/05 30/7/05 Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 23 the home. 26. OP 38 13 (5), (4) (C) The registered person must make arrangements to provide a system for moving and handling service users by arranging up-todate moving and handling training for all staff. The registered person must also make suitable arrangements for the training of staff in first aid. (Timescale of the 31 December 2004 not met). The registered person must ensure that all equipment at the home is appropriately serviced. The registered person shall after consultation with the fire authority, take adequate precautions against the risk of fire including fire drills. A fire risk assessment must be developed and fire safety training provided for all staff working at the care home. (Timescale 8 November 2004 not met). The registered person must ensure that there are adequate supplies of accident books at all times. 30/6/05 27. 28. OP 38 OP 38 23(2)(C) 23(4) 30/8/05 30/7/05 29. OP 38 30/6/05 30. 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 OP 2 Good Practice Recommendations The registered person should ensure that all residents are given a copy of the terms and conditions of their residency at the home regardless of the source of funding. The registered person should keep a copy of the terms and conditions of residency on each presidents personal file. The statement of terms and conditions should make clear, F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 24 Melrose Residential Home 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. OP 3 OP 4 OP 4 OP 4 OP 7 OP 7 OP 8 OP 8 OP 9 OP 9 OP 11 OP 11 OP 12 OP 12 OP 12 Op 12 OP 12 OP 12 OP 16 21. OP 16 who is responsible to the payment of fees. It is strongly recommended that the pre admission document is revised to cover all the topics detailed in 3.3 of the national minimum standards. It is strongly recommended that the registered person obtain reference material for staff on conditions related to old age, particularly dementia. The registered person should ensure that copies of assessments requested by the previous inspector are submitted to the Commission for Social Care Inspection. The registered person should ensure that a training needs analysis is undertaken, and any training needs identified are addressed. Care plans should contain details of all medical needs. Care plans should be reviewed monthly, and updated if necessary. The registered person should give consideration to using the term bed rails, rather than cot sides. The register person should give consideration to disseminating information to residents and their relatives in relation to the use of bed rails. The registered person should retain control drugs register. The registered person should ensure that medication reviews are undertaken. It is strongly recommended that the registered person arrange staff training in care of the dying person. The death and dying policy should be revised to include all information detailed in standard 11. The policy should be specific to the home. It is strongly recommended that the registered person employed an activities organiser. A record of activities undertaken should be kept. It is strongly recommended that the registered manager has access to an adequate budget for activities. It is strongly recommended that the registered person purchases appropriate activity accessories and equipment. It is recommended that the registered manager organises regular residents meetings. The registered person should ensure that up to date information about activities is available to all residents in appropriate formats. The registered person should include the details of the local government ombudsman in the complaints policy. The policy should make clear that complainants are able to approach the Commission for Social Care Inspection at any stage of the complaint. References in the complaints policy to the National care F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 25 Melrose Residential Home 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. OP 21 OP 24 OP 24 OP 24 OP 24 OP 26 OP 27 OP 27 OP 27 OP 28 OP 29 OP 29 OP 29 OP 29 OP 30 OP30 OP 30 OP 31 OP 36 standards commission shall be replaced by the Commission for Social Care Inspection. All complaints information available in the home should be consistent and staff should be fully aware of the policy and procedure. It is recommended that a sluice facility be provided at the home. The registered person should ensure that suitable locks are fitted to the doors of residents rooms. All residents,should be offered the key to their private room, subject to a risk assessment. All rooms should have curtains fitted, all curtains should fit correctly. All light fittings should have lampshades. The registered person, should provide evidence that the services and facilities comply with the Water Supply (water fittings) Regulations 1999. The staff rota should make clear in what capacity staff of employee. It is strongly recommended that the registered manager has designated supernumerary hours, to enable her to fulfil her managerial responsibilities. Dependency levels of people living at the home short be reviewed and evaluated regularly and staffing levels determined accordingly. The registered person should ensure that at least 50 of staff are qualified to NVQ level 2 or above by 2005. The registered person should ensure that all staff are given copies of the code of conduct and practice set by the General Social Care Council. The registered person should ensure that all staff are given copies of their job description. The registered person should ensure that all the staff are given terms and conditions of their employment. The registered person should ensure that the homes application form, meets equal opportunities employment legislation. It is strongly recommended that the registered person draws up a training programme of foundation training. It is strongly recommended that the induction and foundation training meets TOPSS standards. It is strongly recommended that the registered person should ensure that the training and development programme includes mandatory training for all staff. It is recommended that the registered manager obtain a relevant management qualification by 2005. It is recommended that staff receive formal supervision. at least six times per year. F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 26 Melrose Residential Home 41. 42. 43. 44. 45. 46. 47. OP 38 OP 38 OP 38 OP 38 It is strongly recommended that the registered manager has a budget to purchase essential supplies such as accident books. It is strongly recommended that the registered manager undertakes risk assessments for all safe working practice topics. The registered manager must ensure that all staff are trained in how to complete the accident book correctly. All staff should receive induction of foundation training and updates to meet TOPSS specification on all safe working practices topics. Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley, PR7 1NW 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. Extracts may not be used or reproduced without the express permission of CSCI Melrose Residential Home F57 F08 S39455 Melrose V223835 260405 Stage 4.doc Version 1.30 Page 28 - 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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