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Inspection on 19/05/06 for Mother Redcaps Nursing Home

Also see our care home review for Mother Redcaps Nursing Home for more information

This inspection was carried out on 19th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

The home has a group of staff that have worked at the home for some time. They are keen to see standards of care continue to improve and are eager to work with the new management regime towards meeting previous requirements. Most service users spoken to on the day of the inspection praised the care staff for their kindness and respect. Service users also stated that staff have built good relationships with them and work hard to improve their quality of life. All of the service users spoken to informed the inspectors that they enjoyed meals served in the home. Drinks and food are available in the home throughout the day.

What has improved since the last inspection?

Since the previous unannounced inspection, Mother Redcaps has shown improvement in most areas, including meeting the majority of requirements issued in the last report. This home now benefits from a happier staff team, working together for the benefit of the service users; and from an organised management approach to compliance with Care Homes Regulations 2001. Night staffing levels are now compliant on most nights, and staff training, recruitment, personnel files, service user care plans, and medication are the areas of most improvement.

What the care home could do better:

Mother Redcaps still needs to meet all issued requirements within the given timescales, and needs to improve record keeping in all areas; especially updating of care plans, staff supervision and daily reports. The care staffing levels on the top floor during the afternoon (2-8 shift), need increasing to provide adequate care to all service users, especially those in the main lounge. Documented staff supervision requires improvement, as does some areas of risk assessment and recording in care files.

CARE HOMES FOR OLDER PEOPLE Mother Redcaps Nursing Home Lincoln Drive Egremont Promenade Wallasey Wirral CH45 7PL Lead Inspector Julie King & Maggy Howells Key Unannounced Inspection 09:30 19th & 20th May 2006 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 Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mother Redcaps Nursing Home Address Lincoln Drive Egremont Promenade Wallasey Wirral CH45 7PL 0151 639 5886 0151 630 2295 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) Business & Marketing Consultants Limited Susan Vick Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (2) of places Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 51 older persons may be accommodated of whom no more than 2 adults shall be in the category PD and two named adult under 65 years of age. Provide accommodation for two named service users for personal care OP (PC). 21st December 2005 Date of last inspection Brief Description of the Service: This care home is a three-storey purpose built nursing home, situated on Egremont Promenade overlooking the river Mersey, and offers nursing care for 51 older persons. A lounge/dining room is provided on each floor with televisions, videos, piano, and music centres available. The home is double glazed throughout and ramp access is available at the front entrance. A lift serves all floors. All accommodation offered is in single rooms and the majority have the benefit of en-suite facilities. A selection of bathrooms, showers and toilets are provided on each floor and assisted bathing facilities are available. The small front and side gardens are well maintained and car parking is provided at the front of the building. The range of fees are from local social service rates to £481. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days, during which time all the National Minimum Standards for older people were assessed. The lead inspector was accompanied by the specialist Pharmacy Inspector, Maggy Howells; who will produce a separate pharmacy report in due course. A full tour of the premises took place, and staff and care records, along with medication records, were inspected. The inspectors spoke to most staff on duty, plus the majority of service users and some visitors. Since the previous inspection in December 2005, a new Operations Manager has been appointed, and significant improvements were evident in a number of areas. A new manager has also been appointed, and again, positive changes were noted in the day-to-day management of this care home. What the service does well: What has improved since the last inspection? Since the previous unannounced inspection, Mother Redcaps has shown improvement in most areas, including meeting the majority of requirements issued in the last report. This home now benefits from a happier staff team, working together for the benefit of the service users; and from an organised management approach to compliance with Care Homes Regulations 2001. Night staffing levels are now compliant on most nights, and staff training, recruitment, personnel files, service user care plans, and medication are the areas of most improvement. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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 Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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 the following standard(s): 1,2,3,4,5. (Standard 6 not applicable). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide now provides enough information for prospective service users so they can be clear about the services the home provides to meet their care needs. EVIDENCE: The Statement of Purpose and Service User Guide collectively now cover all the items required, although they are presented in a slightly different format. The last inspection report is now available on the main notice board for all to see. Contracts are issued to service users who are privately or state funded, but the ones seen did not include the actual room number to be occupied. The Operations Manager informed the inspector that the administrator had just completed revising contracts to include room numbers for privately funded service users, and these will be issued shortly. Pre-admission documentation was examined for all service users admitted after the new Operations Manager and manager commenced employment. The assessments varied according to which paperwork was used, for example, the Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 9 documentation of the first service users who were admitted on last year’s paperwork did not evidence a holistic assessment. The recently revised documentation now in use evidenced a holistic individualised approach which now includes aspects of risk assessment and family involvement. The subsequent care plan was then based on these assessments, and specialist needs of the service users were identified during this process. All service users are offered trial visits prior to admission, and this information is re-iterated in the Statement of Purpose and Service User Guides. Mother Redcaps does not provide intermediate care. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans, risk assessments, daily health records for each the residents are checked by the acting manager or Operations Manager in the home. This ensures that the care needs of the residents are identified, and the appropriate care given by carers. EVIDENCE: Service users who had been admitted since the previous inspection, plus others with specific needs were case-tracked during this unannounced inspection. During the case-tracking process, all related care files and related records were examined. A new care planning system is currently being introduced by the Operations Manager & acting manager, and was in use in some files. Other service user’s files evidenced a mix of the previous documentation and the new documentation, but the inspector was informed that the acting manager and qualified staff will concentrate on upgrading all care plans over the next couple of months. Most care plans have improved considerably since the previous inspection, and generally evidence colour photographic identification of each service user, Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 11 biography / life story for relatives to complete with the service user and a care needs summary with associated risks. Also evident in the service user’s records were actual and potential problems based on the Roper, Logan & Tierney model of nursing care; dependency rating assessment tool; moving & handling assessments including weights; nutritional risk assessments; bedrail risk assessments including consent; Waterlow (tissue viability) risk assessments; continence assessments; monthly observations; behaviour chart to be used as needed; daily reports with day & night entries by qualified nurses; significant conversations records to include family conversations / information; multidisciplinary healthcare team (MDT) visits including NHS and GP; individualised recreation & leisure record; identified pre-admission assessments evolving into care plans; emotional well being assessment; arrangements for terminal and after death care. However, there is still a lack of understanding by qualified staff, albeit to a lesser extent than previously, who were spoken to in respect of the difference between the assessment carried out by the long term care team for registered nurse input is invariably ‘Medium Dependency,’ and the dependency level that they were required to assess. This inaccurate use of the care documentation has resulted in most of the service users being classed as medium dependency, when their daily reports strongly suggest high dependency. Medications have shown the greatest area of improvement, and on the day of this inspection evidenced full compliance with the required standard. The specialist pharmacist inspector will produce a separate pharmacy report in due course. Personal support in the home is offered in such a way as to promote and protect the service user’s privacy, dignity and independence. Staff were observed knocking on service user’s bedroom doors prior to entering, and service user’s spoken to said that “the staff are nice”. The service users also said the staff in the home were always courteous, respectful, and maintained their privacy and dignity when giving personal care. All service users in the home can access their NHS entitlements, such as opticians, dentist, etc; and care staff (if staffing levels allow) escort the service users to their hospital appointments. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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 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. Service users social, cultural, religious and recreational interests and needs are not being fully met; potentially leading to feelings of boredom amongst the service users. The food offered at Mother Redcaps is good, helping to ensure a wholesome and varied diet for all service users. EVIDENCE: On admission to the home service users are asked about their choices and preferences as regards food, past social life and hobbies. This information is used by care staff to plan diets and activities for the service user. An activities organiser has recently been recruited, and is due to commence work within the next couple of weeks. In the meantime carers are trying to provide limited activities for service users, but due to the minimum staffing levels, activities have not been actively promoted during the last few months. An activities program is posted in the main hall of the home, but it was clearly evident that mostly the promoted plans do not take place. Service users, relatives and carers who discussed this, said there were very little organised Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 13 activities for service users and they were looking forward to having a designated person in the very near future. Some service users have been going for short outings recently which they very much enjoyed. However the staffing levels at the home in the afternoon do not allow for care staff taking service users out, leaving the home short-staffed during the time other staff are taking service users out into the local community. The activities co-ordinator, once commenced, will need training and guidance as to why and how suitable activities are offered to service users, and the importance of documenting information on how service users participate in activities. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 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 the following standard(s): 16,17,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints and adult protection policy and procedure was in place that helps ensure the safety and welfare of residents. EVIDENCE: Since the previous inspection there have been noticeable improvements in staff training in the prevention of adult abuse. The Operations Manager has provided training to most staff, including care, housekeeping and kitchen staff; and records of this training are now being kept. There has been a number of complaints made about this service since the previous inspection, some of which have been upheld; but all complaints since the previous inspection have been dealt with by the Operations manager, with audits, outcomes and action plans produced. Relatives spoken to informed the inspectors that they would have no worries about approaching staff or management if they had any concerns, and the contact details of CSCI were readily available. However a number of relatives / service user questionnaires were returned to the CSCI which stated that that they were unaware of the home’s complaints procedure. The majority of complaints received at the home and CSCI have been directly or indirectly related to the staffing levels of this service. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 15 The home procedures which includes information on ‘whistle-blowing’, in accordance with the Department of Health ‘No Secrets’ guidelines, and some advocacy information is available as needed. There is no religious or political persuasion at Mother Redcaps, and service users are enabled to participate in voting, etc; as they wish. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Since the previous inspection the standard of cleanliness and décor within the home has improved, presenting in most areas as a homely and comfortable environment for service users. EVIDENCE: Numerous areas have had new flooring and /or been redecorated since the previous inspection, and the overall standard of cleanliness in all areas has improved. However there are still a number of bedrooms and communal areas that require redecoration and /or refurbishment, especially some bedroom floor covers which are in need of replacement. There was no malodour in any area, and the overflowing waste problem from the previous inspection was seen to be cleared. The garden was overgrown, and the inspector was informed that the gardener was no longer working at the home, but one of the care staff was tending to the grounds. It was strongly recommended that a gardener is contracted on a regular basis to tidy and Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 17 maintain the grounds, as currently the service users are restricted to limited areas of the garden due to the overgrowth. Most service users bedrooms and all communal areas, including the basement were examined over a two day period. Extractor fans in all bathrooms and sluices were not working, and one of the final exit fire escape doors on the lower ground floor was not closing fully into it’s rebate. The Operations Manager was required to risk assess and take appropriate action on the handyman’s store in the basement which was found to be cluttered with combustibles and had no smoke/heat detector in situ. The majority of service user’s bedrooms were personalized with their artefacts and possessions, and some evidenced relative/family involvement. New bedlinen had been obtained, with more apparently on order. Pressure relieving mattresses and cushions were seen, as were lifting and mobility aids, and specialist equipment as needed. It was recommended that the cleaning hours are not reduced at holiday times, but additional cover is sought to ensure the current standard of cleanliness is at least maintained, if not improved. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is now a consistency of care within the home provided by permanent staff, which helps to offer safety and stability for the residents. Further work is still necessary to fully comply with staff training and development. EVIDENCE: All staff that had commenced employment since 01 January 2006 had their personnel files examined, and since the previous inspection there has been improvement in staff personnel files and general recruitment practices. References were seen in all files, and CRB and POVA information was also evident. However it was recommended that copies of all information required for CRB purposes are held on staff files. The Operations Manager was clearly able to inform the inspector of their knowledge of the National Minimum Standards and accompanying regulations regarding the recruitment and retention of staff. Training and inductions, including specific training on the protection of vulnerable adults was seen for most staff. The Operations Manager and acting manager have developed a training plan for all staff, accessing some external training providers. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 19 The range of training and development includes medication management, moving & handling, health & safety, pressure sore prevention and NVQ in Care. This improvement should continue to be built upon. The acting manager is also in the process of establishing “link people” to obtain additional information and training as needed. Their role will also extend to cascade new information to the remainder of the home’s staff. Separate training files for all staff have now been set up, and a ‘training calendar’ has also been devised by the Operations Manager, highlighting who and when needs which training. The home has now joined ‘Wirral Partnerships in Training’, which has allowed them to access a wide range of mandatory and specialist training for all grades of staff. Qualified staff have received specialist medication management training from the community pharmacist, and two of the registered nurses are in process of doing their NVQ 4 in Care Management. The inspectors were informed that in order to strengthen the staff team, the home are currently recruiting for the post of deputy manager, who can further develop training and staff supervision. An ongoing requirement will be issued for staff supervision – the Operations Manager has just commenced training in this regard, but no formal supervision sessions have been recorded. The service users assessed and collective care needs should be reflected on the levels of qualified and care staff on duty at any given time, and the current staffing levels are the minimum needed; and must not be regarded as the maximum, or be reduced. Examination of the staffing rota evidenced that most days and nights the home was compliant with minimum staffing levels, with the occasional night being short of the required two qualified staff. It is strongly recommended that urgent consideration be given to maintain the morning staffing levels on the top floor, and not reduce the 2-8 shift by one carer. This was raised as a concern by relatives spoken to during the inspection, who told the inspectors that the service users are often left unattended in the lounge in the afternoon whilst the care staff were attending to other service users who were in staying in their bedrooms. This was directly observed by the inspectors who saw service users having to wait to go to the bathroom, etc; causing them some anxiety and distress. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. After a period of considerable instability in staffing there is now a consistency of care within the home provided by permanent staff, which helps to offer safety and stability for the service users. Further work is still necessary to fully comply with staff supervision in practice. EVIDENCE: The new manager is in process of registration with the CSCI, and apparently is going to commenced his NVQ 4/RMA in the near future. All staff spoken to informed the inspector that they felt “much happier than last time”, and the home “was more settled now”. They also said that they were pleased with the improvements and that they “felt supported”, and valued the “professional approach of the Operations Manager”. The service users also told the inspector that they were happy and felt “able to talk to the staff about anything”. Relatives spoken to also expressed their increased confidence in the home’s internal management systems, and felt Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 21 that overall care had improved; but concerns were still present re afternoon staffing levels. Policies and procedures are on an ongoing process of updating in accordance with changes in legislation, with some recently completed and others still to update. Safety certificates were in date and valid., but the hoist on the top floor was not working properly and requires repair or replacement as soon as possible. It was also recommended that a Legionella test be completed on the water, as the previous test was carried out in 2002. Some quality assurance is in place although this must be further improved to fully comply with regulation. It is also important that all staff receive regular supervision in line with this standard. Patient’s monies are kept in separate, secure facilities, and records and receipts of transactions were seen. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 2 3 3 Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 23 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 The registered person must produce a care plan for each service user (service user) that must be kept relevant and updated on a regular basis. Previous timescale of 28/02/06 not met. Timescale for action 30/07/06 2. OP19 23 The registered person must 31/08/06 ensure that the care home is in a good state of repair and reasonably decorated at all times, including the external grounds. The registered person must ensure that there is sufficient staff on duty at all times. Timescale for action: 19/05/06 and ongoing 19/05/06 3. OP27 18 4. OP33 24 The registered person must 31/08/06 ensure appropriate quality assurance process is commenced with the involvement of service users and their representatives. Previous timescale of 31/01/06 not met. Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 24 5. OP12 12 The registered person must 30/06/06 ensure that all service users are enabled, as they so wish, to participate in fulfilling activities of their choice - and these offered activities must be recorded whether or not they are participated in. Previous timescale of 31/01/06 not met. The registered person must ensure that the furnishings are of a suitable and adequate standard in all areas of the care home. The registered person is required to ensure that suitably qualified staff are on duty at all times. Timescale for action: 19/05/06 and ongoing The registered person must ensure that all staff are appropriately supervised, and records of this are kept. Previous timescale of 31/03/06 not met. The registered person must keep all fire exits and escapes in full working order at all times. Timescale for action: 19/05/06 and ongoing The registered person must comply with requirements and regulations as specified, within the given timescales - failure to do so shall be an offence. 31/08/06 6. OP20 16 7. OP28 18 19/05/06 8. OP36 18 30/07/06 9. OP19 23 (4) 19/05/06 10. OP31 43 31/08/06 Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 25 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 OP8 Good Practice Recommendations It is strongly recommended that all accidents, falls and untoward incidents are clearly audited and recorded by the homes management at least monthly. Additional risk assessments and checklists related to equipment and environment would help safeguard service users. 2. OP38 Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mother Redcaps Nursing Home DS0000020940.V289261.R02.S.doc Version 5.1 Page 27 - 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. 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