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Inspection on 07/06/05 for Michaelstowe Hall Residential and Nursing Home

Also see our care home review for Michaelstowe Hall Residential and Nursing Home for more information

This inspection was carried out on 7th June 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

Michaelstowe had been partially refurbished and in those areas provides a comfortable and homely place to live, with a range of pleasant communal areas and bedrooms with individual character. Residents and relatives spoken with said that staff were friendly and caring. Residents who commented upon the food, said it was good and there was plenty to eat and drink.

What has improved since the last inspection?

Since the last inspection, a manager has been appointed, improvements in the administration and recording of medicines were evident, a drug audit has been undertaken, 3 care staff have been assessed for competencies in administration of medicines, job descriptions are being reviewed, food hygiene training has been provided for 6 staff, in-house infection control training for 2 care staff and handover between shifts is now recorded. The standard of care had notably improved for 2 residents and included some rehabilitation. Refurbishment of part of the premises has been undertaken and some new furniture provided.

What the care home could do better:

The security of the premises does not ensure the safety of residents and as this is primarily due to staff not locking doors, systems such as digital locks need to be given urgent consideration. Action is required to remove malodorous smells from the home to enhance the environment and reduce the risk if infection. This may be due to poor care practice but may also require change of some carpets. Care plans did not provide sufficient detail to ensure that care staff are fully informed on residents` individual needs when providing care. Reviews need to be undertaken more frequently and recorded on a new care plan rather than amending existing care plans in order to provide clear instruction for staff. The processes for recruiting new staff need to be improved to ensure that all the appropriate checks are undertaken prior to appointment of staff. Staffing levels need to be increased to ensure residents` needs are adequately met at all times. The management of complaints and quality of investigation and response to complainants needs to be improved to assure residents and their relatives that their concerns are taken seriously and acted upon. Adherence to Protection of Vulnerable Adults procedures is essential to ensure the safety and protection of residents.

CARE HOMES FOR OLDER PEOPLE Michaelstowe Hall Residential and Nursing Home Ramsey Road Ramsey Harwich Essex CO12 5EP Lead Inspector Diana Green Unannounced 7 June 2005 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. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Michaelstowe Hall Nursing and Residential Home Address Ramsey Road Ramsey Harwich Essex CO12 5EP 01255 880308 01255 880907 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) Handylodge Limited Care Home Category(ies) of Old age, not falling within any other category registration, with number (61), Physical disability (10), Physical disability of places over 65 years of age (50) Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Persons of either sex, aged 40 years and over, who require nursing care by reason of a physical illness/disability (not to exceed 10 persons) 2 Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical illness/disability (not to exceed 50 persons) 3 Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 46 persons in Oakland Unit) 4 Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 15 persons in Greenland Unit) 5 One person, under the age of 40 years, who requires care by reason of a physical disability, whose name was made known to the Commision in January 6 The total number of service users accommodated in the home must not exceed 96 persons Date of last inspection 30 March 2005 Brief Description of the Service: Michaelstowe Hall provides personal and nursing care with accommodation for up to 96 older people and can accommodate 10 service users aged 40 years and above with a physical disability. Michaelstowe Hall is owned by a private organisation named Handylodge Ltd.The home is located in the village of Ramsey, Harwich, Essex. The home was opened in 1995 and is a 3 storey Victorian building. The home is divided into 2 separate units: Oaklands, which provides personal care only and Greenlands, which provides personal and nursing care. There are 64 single rooms including 60 with en-suite toilet facilities and 14 shared rooms, all with en-suite toilet facilities. There is a passenger lift. The home has large attractive gardens overlooking open countryside and a courtyard garden accessible to wheelchair users. Michaelstowe Hall is accessible by road and has good bus links. Parking is available in the car park. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection on 7th June 2005, beginning at 09.40 and ending at 14.00 hours. The main purpose of the inspection was to follow up compliance with the requirements and recommendations made following the inspection of 30th March 2005. The inspection process included: discussions with the manager, the administrator, the maintenance person, the laundry assistant, six care staff, four service users and three relatives; a partial tour of premises, inspection of medication, observation of lunch and the inspection of a number of records kept by the home. Sixteen standards were inspected, of which 3 were met and the remainder consisted of minor shortfalls, resulting in 17 requirements and 3 recommendations. Residents and their relatives spoken to were generally satisfied with the care at the home and said that staff were friendly and caring. One resident said “care staff are friendly but they are under pressure” Other comments from residents were “I have no complaints about the food”. “The food is good here”. One relative said “the cleaning is good and the care satisfactory.” What the service does well: Michaelstowe had been partially refurbished and in those areas provides a comfortable and homely place to live, with a range of pleasant communal areas and bedrooms with individual character. Residents and relatives spoken with said that staff were friendly and caring. Residents who commented upon the food, said it was good and there was plenty to eat and drink. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 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 Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 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) 3 The admission process has improved. However, residents continue to be admitted with no assurance that their care needs can be met. EVIDENCE: The improvements in assessments identified at the previous inspection had been maintained from the four residents’ files sampled. All four had an assessment of needs undertaken that included all elements as detailed under the standard. Daily records were recorded in all of the four files sampled with one being particularly well detailed. Risk assessments for falls had been undertaken for three service users. Risk assessments for use of bed-rails where relevant were recorded and signed by representatives of service users. Nutritional assessments and manual handling assessments were recorded for the four service users. Nutritional intake and weight monitoring was recorded. However one weight was erroneously recorded indicating a 2 stone weight increase. Staff signatures were recorded using one initial and not their surname. Reviews been undertaken for two residents and a review of one service user who had been admitted with a mental disorder had not yet been actioned. The standards for choice of home, contract, meeting needs and trial visits were not inspected. This home does not provide intermediate care. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 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 Care planning systems have progressed but need further sustained development to provide care staff with adequate information they need to enable them to meet residents’ needs. The health care needs of residents are generally met but without qualified and updated registered nurses employed in sufficient numbers, residents continue to be at potential risk. The standards for storage, administration, and recording of medication, whilst improving are not sufficiently robust, potentially placing residents at risk. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 10 EVIDENCE: Four residents’ files were sampled and all had a plan of care that provided evidence of consultation with residents/relatives. One care plan was brief but improvements were noted in the detail of the remaining three care plans. All four care plans had been reviewed monthly and amendments made to the existing care plan rather than recording an updated plan. The detail of the daily records had improved and was comprehensively recorded one record evidencing that care was well monitored and action taken where necessary to improve care. Risk assessments were recorded for falls, weight monitoring was undertaken and nutritional records were maintained. An error in the recording of one resident’s weight was evident as indicated under standard 3. Service users were observed to have their personal care needs met and to be well cared for. There was evidence from the records sampled of referral to GP’s, specialist medical, nursing, chiropody and clinical nurse specialists, although this was maintained in a separate record and not reflected in the care plan. The home continued to receive support and advice from the Clinical Nurse Specialist Tissue Viability and Community Nurses in the care of residents with nursing needs and in particular those with pressure sores. From the records it was evident that chiropody was provided at 3 monthly intervals and not six weekly as would normally be expected. This was discussed with the manager who was aware and in the process of arranging more frequent sessions to be provided. Improvements in the handling and recording of medicines evident at the previous inspection had been maintained. Action had been taken to ensure that all controlled drugs returns were appropriately signed for with the address of the supplying pharmacist recorded. There were two residents who were selfmedicating in Oaklands Unit. All had a risk assessment recorded but both required a review. The manager, a registered nurse, midwife and community practice teacher/assessor had undertaken an audit of medicines administration. The manager had undertaken a written assessment for three senior care staff and one was assessed as requiring additional training. The manager said she intended to undertake an assessment for all care staff with responsibility for medicines administration. Monitoring of fridge temperatures had been undertaken and recorded daily in Oaklands Unit and was satisfactory, but there were three occasions in Greenlands Unit where no record was evident. There were no medicines for administration in variable doses at the time of this inspection. Medication reviews had been undertaken including one resident with mental health needs who was waiting transfer to a suitable home. Recording of medicines administration had improved with no omissions and handwritten instructions were dated and signed as required. There was no signature recognition list for care staff on Oaklands Unit and on Greenlands Unit the qualified nurse signature recognition list included the full Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 11 signature but not initials of staff. Senior care assistants were using only one letter of their signature to confirm administration. Codes used to indicate nonadministration, refusal etc. were confusing and not as indicated on the MAR sheet. The commission had received a complaint that one resident had not received a recently prescribed medication for Parkinsons Disease for three days. The records confirmed that three doses had been omitted due to an error by the supplying pharmacy. The manager was aware and had addressed this and another problem in consultation with the supplying pharmacy. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Michaelstowe does not provide sufficient social, cultural, religious and recreational activities to enrich residents’ lives. The meals in this home provide an adequate choice and variety to meet the culture and lifestyle expectations of residents. The nutritional needs of residents are potentially compromised by the lack of provision of snacks at other times. EVIDENCE: The standard for social activities was not fully inspected. One service user 52 years who had recently been admitted said there were no activities provided that were suitable for them and the manager had remonstrated with them when they went out for the evening. There were no social activities evident on the day and residents were observed to be sitting in wheelchairs in the dining rooms and lounges without any stimulation apart from a television. A notice on display indicated that there were no planned activities for the period from 822nd June when the activities coordinator was due to be on annual leave. Residents spoken with said that they enjoyed the meals provided and one resident said the food was generally good and there was plenty to drink but there were no snacks provided between the supper at 5pm and breakfast at 8am the following morning. The menus comprised homely type food and special diets were catered for. There was evidence that nutritional and fluid intake was monitored and recorded. From observation, inspection of records and discussion with staff there was evidence that attention was required to Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 13 ensure all fluids were accurately recorded, particularly where residents were at risk of dehydration Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints process in this home is unsatisfactory with little evidence that residents or their representatives have their views listened to or acted upon. EVIDENCE: The Commission had received four complaints since the last inspection comprising: • Premises health and safety, low staffing levels, lack of hairdressing and malodorous smells- outcome partially upheld for low staffing levels and malodorous smells. • Medication not administered for 3 days-outcome partially upheld as 3 doses were missed not 3 days. • Staff bullying-outcome unresolved. • Lack of personal care-currently under investigation. The home has a complaints procedure specifying timescales in which complainants can expect a response. However one complainant has received no response from a complaint made in November 2004, and in a second complaint made in November 2004 and investigated by the Provider, the complainant has received no response to their letters indicating their dissatisfaction. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 15 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, 24 &26 Some progress has been made to improving the décor and environment of Michaelstowe but the safety of residents remains compromised by inadequate premises security and lack of facilities in residents’ rooms. The standard of infection control at Michaelstowe has improved through the provision of facilities and staff training but continues to detract from the environment and potentially affect the heath and safety of residents. EVIDENCE: The home was in the process of refurbishment and Oakland Unit had been redecorated with some new carpets laid and new furniture provided to recently decorated rooms. The entrance to Oakland unit was locked on arrival and the entrance to Greenlands unit was also locked. However the rear entrance to Greenlands, where clinical waste bins are stored, was found to be unlocked and as the home is located in a rural area with no secure boundary fence, this places residents at risk. The manager was aware that staff were leaving doors unlocked and had spoken with them emphasising the security risk and was monitoring the situation. However a more secure practical solution such as digital locks needs to be given urgent consideration. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 16 Standard 24 was not fully inspected. However it was evident that residents do not have suitable locks fitted to their rooms and there are no lockable facilities provided in most rooms. Service users therefore have no facilities to store money or valuables, potentially placing them at risk of abuse and compromising their independence. One resident had alleged the theft of monies from their room recently that had not been reported under procedures for the protection of vulnerable adults or to the commission as required. The home was observed to be generally clean and hygienic and infection control practices generally well adhered to. However there remained several rooms on Oaklands Unit that had a malodorous smell. Also on Greenlands Unit there was a malodorous smell when residents were receiving personal care, indicating poor care practice or that residents continence needs were not being appropriately met. One of the three clinical waste bins was observed to be unlocked. The laundry was large and equipped as required. Large amounts of used linen and clothing were observed waiting to be laundered during the morning. However by the end of the inspection this situation had been resolved Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 17 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, 29 & 30 The staffing levels and skill mix do not meet those required by the commission. Without the provision of adequate staffing levels, the needs of residents cannot be appropriately met. Michaelstowe has made limited progress in improving the standard of vetting and recruitment practices; checks to ensure the protection of residents are not carried out effectively. EVIDENCE: There were twenty-eight residents on Greenlands Unit for which the staffing levels comprised two registered nurses, two care assistants and one care assistant on induction. This was less than the required staffing levels of two registered nurses and five care assistants. Two additional registered nurses had been recruited to the home. On Oaklands Unit there were twenty-three service users for which the staffing levels comprised one senior care assistant and three care assistants. A recorded staff rota showing which staff are on duty and in what capacity was in place. Two staff files were sampled for staff recently employed. One had evidence of identification held on file with a copy of birth certificate, passport and Criminal Records Disclosure but no references and the second had no identification and only one reference. There was no evidence of work permits available for staff recruited from overseas. Standard for staff training was not fully inspected however six staff had been booked to attend food hygiene training, four staff were booked for induction Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 18 training to NTO specification and two staff had received in-house training in infection control. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 19 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, 37 & 38 The manager had a good understanding of the areas in which the home needs to improve and some progress had been made in gaining staff confidence. Michaelstowe does not always adhere to the protection of vulnerable adults procedures. The rights and best interests of residents are therefore not appropriately safeguarded. The health and safety systems at the home continue to improve but are not sufficiently robust to ensure staff and residents are safe at all times. EVIDENCE: The manager had been in post for four weeks. She is a registered nurse, registered midwife, district nurse and community practice teacher/assessor and had considerable experience in management. An administrative assistant supported the manager and the proprietor was also in regular attendance at the home. The manager had made some progress in reviewing job descriptions and was in the process of assessing staff competencies. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 20 The standard for records was not fully inspected but there was no record made of possessions on admission in one file sampled. An alleged theft had not been reported under POVA procedures or to the Commission as required. Health and safety practices were generally adhered to, and progress made in improving the environment. However delays in maintenance/environmental issues being dealt with means that Michaelstowe does not always present as safe. An external door was also observed to be unlocked. Two trolleys containing COSSH items (control of substances hazardous to health) were observed unsupervised and a clinical waste bin was noted to be unlocked, posing a health and safety risk to residents. Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 21 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x 2 2 Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 22 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 7 Regulation 15(1) & 15(2) Requirement The registered person must ensure that all residents have a care plan that provides clear instruction to staff, is regularly reviewed and updated to reflect changing needs. The registered persons must ensure that residents medication is administered as prescribed The registered person must ensure that residents who are self medicating have a risk assessment that is regularly reviewed. The registered person must ensure that all residents have a lockable facility for medication, money and valuables. This is a 3rd repeat requirement The registered person must ensure that social activities are provided to meet the social, cultural, religious and recreational needs of residents The registered person must ensure that snacks are provided for residents between 5pm and 8am The registered person must ensure that all complaints are fully investigated and Timescale for action Immediate informed at inspection 2. 3. 9 9 13(6) 13(2) Immediate informed at inspection Immediate, informed at inspection Immediate on receipt of report 30/08/05 4. 9 12(4)(10, 13(4) & 23(2)(m0 16(2)(m) & !6(2)(n) 5. 12 6. 15 16(2)(i) Immediate in receipt of report Immediate on receipt of report Page 23 7. 16 22(4) Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 8. 19 13(4) 9. 24 13(4) 10. 11. 26 & 38 26 13(4) 13(3) 12. 27 18(1) 13. 29 7, 9, 19 Schedule 2 14. 15. 29 33 19 Schedule 2 26(4) 16. 37 & 18 13(4) & 37 17. 38 13(4) complainants receive a satisfactory response within 28 days The registered person must ensure that the security of the premises ensures the safety of residents The registered person must ensure that pre-set valves are fitted as part of a risk assessment to ensure water is distributed near to 43degrees Centigrade to prevent the risk of Scalding. A date for fitting to be agreed with the commission The registered person must ensure that clinical waste bins are locked at all times The registered person must ensure that malodorous smells are removed from the home to include rooms 28, 31 & 34. The registered person must ensure that 2 registered nurses and 5 care assistants are on duty on Greenlands Unit The registered person must ensure that two satisfactory references are obtained prior to appointment. This is a 2nd repeat requirement. The registered person must ensure that a recent photograph of all staff is held on file The registered person must ensure that monthly reports of the conduct of the care home are provided to the commission The registered person must ensure that all incidents of alleged abuse are referred under POVA procedures and the commission is notified The registered person must ensure that all items subject to COSSH (control of substances hazardous to health) are kept Immediate, informed at inspection On receipt of report. Immediate, informed at inspection 30/07/05 Immediate informed at inspection Immediate informed at inspection Immediate Immediate on receipt of report Immediate Immediate, informed at inspection Page 24 Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 locked when not supervised. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 8 29 37 Good Practice Recommendations The registered person should ensure that chiropody treatment is provided at six weekly intervals The registered person should ensure that work permits where relevant are available for inspection The registered person should ensure that a record of the residents clothing and other possessions is made on admission to the home Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Michaelstowe Hall Residential and Nursing Home I56-I05 S15326 Michaelstowe Hall V232867 070605 Stage 4.doc Version 1.40 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!