CARE HOMES FOR OLDER PEOPLE
Netherclay House Bishops Hull Taunton Somerset TA1 5EE Lead Inspector
Caroline Baker Unannounced Inspection 09:15 22 December 2005
nd 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 Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Netherclay House Address Bishops Hull Taunton Somerset TA1 5EE 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) 01823 284127 01823 336765 MR PETER HOWARD WILMOT-ALISTONE MRS LAURA WILMOT-ALLISTONE Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. One named service user under the age of 65 years Rooms 14, 15 and 16 are suitable only for service users who have a degree of physical and mental independence. The Manager must conduct regular assessment and review of service user needs, to ensure that the accommodation and service provided continues to be appropriate. 6th July 2005 Date of last inspection Brief Description of the Service: Netherclay House is a Georgian building with modern extensions that has been a residential home since 1972. The Registered Providers at this time are Mr and Mrs Wilmot-Allistone however Mr Patrick Allistone overseas the home on their behalf. There is no Registered Manager at this time. The home is registered with the Commission for Social Care Inspection to provide personal care to up to 42 people over the age of 65 years. The home provides accommodation for up to thirty-seven service users within the main building, and a further five service users within the bungalows set in the grounds. The home provides meals to persons in their own home as part of the providers Domiciliary Care Agency. Day care is also provided for up to two people per day, which is not registered or inspected by CSCI. Netherclay House currently offers day care, respite care and permanent accommodation. The home does not provide nursing care. Netherclay House provides comfortable and spacious accommodation and is set in large gardens that border the River Tone. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The last inspection was unannounced and took place on 6th July 2005. At that inspection ten requirements were identified and four recommendations were made. This inspection was unannounced and took place from 09:15 hrs over one day (7.5 hours) by Caroline Baker accompanied by Gill Broughton Business Support Administrator. At the time of this inspection five of the requirements had been complied with or partly complied with, and the recommendations had been actioned. This inspection identified a further eight requirements and three recommendations have been made. Since the last inspection the registered manager has left, and the home is actively trying to appoint a new manager. Thirty-eight service users were residing at the home, including one in hospital. Staffing levels were adequate. Not all the National Minimum Standards were assessed at this inspection and this report should be read in conjunction with the last inspection report. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least seventeen service users were spoken with, including four who were case tracked. At least four members of staff on duty were spoken to and the inspector was able to speak with visitors to ask for their views on the conduct of the care home. Throughout the day the inspector was able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection?
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 7 There has been new flooring throughout the extension part of the home, which has enhanced the corridors. One of the rooms had new flooring. A new cook had been employed since the last inspection and menus were being reviewed. Staffing levels had been maintained and staff recruitment continued to include overseas staff. Staff morale was much improved. There had been no complaints since the last inspection. Hand washing facilities had been provided for staff where personal care was provided. Action had been taken to comply with five issues raised at the last inspection. What they could do better:
Care plans sampled evidenced that they were not always reviewed and updated to reflect individual current care needs. The medication policy had not been revised as required at the last inspection. The self-medication policy item 2.1 states - ‘individual locked drawers or cupboards will be provided in the residents rooms’. This was not the case. At least six service users self medicate and do not have a locked area to store them in. This must be provided in line with the homes policy. This was a requirement at the last inspection and had not been actioned. Staff files examined, evidenced that staff had commenced employment before receipt of a Criminal Record Bureau (CRB) disclosure or POVAFirst check, which potentially put service users at risk of harm. For the protection of vulnerable adults, all staff must be made aware of types of abuse and the steps to take should they suspect abuse in line with the homes Whistleblowing policy. The home is without a registered manager at this time and a manager must be employed within the next six months to ensure the continued stability of the home. The complaints policy needed updating to include the Commission’s (CSCI) address and telephone number. Hot water outlets had not been tested or recorded, as required at the last inspection, to ensure temperatures were in line with Health and Safety guidelines.
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 8 Fire doors continued to be wedged open, fire alarms had not been tested on a weekly basis and emergency lighting had not been tested monthly, potentially putting service users at risk of harm should a fire break out at the home. As required at this and the last inspection the provider must consider alternative ways of allowing service users to have their doors left open, for example, individual automatic fire door closures. The storage of denture cleansing tablets needed further consideration. The home should implement its Quality Assurance policy and include regular service user, relatives/representative meetings and quality audits for example surveys to ensure it is providing the best for its service users by gaining their views on the conduct of the care home. Although many issues were raised at this inspection it was evident that the staff and management acknowledged the need for improvement in those areas. The inspector remains satisfied that the home remains fit for its stated purpose and will continue to monitor the home as required. 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. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 9 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 Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 10 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): 2 and 3. NMS 6 does not apply to the home. Service users are given a statement of terms and conditions of stay. Service users where possible are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: Service users contracts of terms and conditions of stay were sampled. The service user and/or their representative had signed those seen. As discussed during the inspection these should also be dated. Four service users care records were examined and the service users met as part of the case tracking process. Evidence was seen in the care records that the home had assessed and gained details of the most recent service users prior to admission to ensure the home could meet their needs. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7; 8; 9; and 11. Each service user had an individual plan of care. Care planning although overall was comprehensive needing some improvement with regard to reviewing. Service users have access to health care professionals ensuring their health care needs were met. The home has a policy for the safe handling of medicines, however for those persons self-medicating it had not been followed and potentially put service users at risk of harm. The medicine policy had not been reviewed as required at the last inspection. Policies were in place to ensure that at the time of death service users would be treated with respect and dignity. EVIDENCE: Four care plans were sampled and the individual service users met as part of the case tracking process. Each care plan contained preferred times of waking and retiring. Risk assessments were available for pressure relief and any individual risks identified which is good practice. Each service user had been
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 12 weighed on a monthly basis to identify any nutritional needs. Two of the care plans sampled had been reviewed and reflected current care needs. One of the service users needs had changed and the care plan did not reflect the care currently required. One of the care plans had not been reviewed since September 2005. These identified issues were brought to the attention of the senior carer in charge at the time of the inspection. It was evident from speaking to service users that they had access to a GP, chiropodist, dentist and optician. District Nursing Services support the home in wound care and pressure ulcer care. District Nursing notes are kept in the individual service users rooms where care is required with wounds. As discussed individual care records should reflect this. Pressure relieving equipment was being used appropriately at the home with advice from the district nurses. Service users spoken with were very happy with the care provision at the home. Relatives spoken to were satisfied with the care provision at the home. Medication policies and systems were examined. Although practice was very good the home was not following its policies. The medicine policy states that a ‘Registered General carer’ must check controlled drugs. The home does not employ Registered staff. The self-medication policy states at 2.1 ‘Individual locked drawers or a cupboard will be provided in the residents room so that drugs/medicines can be stored safely’. The home did not provide lockable spaces in the bedrooms and this had been required at the last inspection. It is required that policies be revised and lockable spaces are provided as discussed. Systems were in place and policies to ensure staff understand the needs of service users who are very ill and dying. The home has had three deaths since the last inspection. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Service users benefit from a range of activities provided by the home to suit their individual choices and needs. Service users are offered nutritious well-balanced menus promoting their health and well-being. EVIDENCE: Service users consulted felt that the activity provision at the home was adequate. Many chose not to join in however, with activities provided. The Christmas activities had begun with a pantomime and a Carol Service. The home was dressed up for Christmas and the atmosphere was warm, homely and happy. Staff wore Christmas décor on their heads and looked very festive. Activities provided and planned were recorded in diary form. Service users consulted praised the food provision at the home and stated that it was plentiful. Menus are planned and posted up on a weekly basis. Service users were not informed of what was on offer each day at lunchtime however were able to access the menu. Service users told the inspector that they had a choice of breakfast and supper and that an alternative was always available at lunchtime. The cook told the inspector that menus were being reviewed in the New Year and that service users would be consulted. Likes and dislikes were
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 14 recorded and records maintained in the kitchen. This will be followed up at the next inspection. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A complaints procedure is made available to service users to allow them to raise any concerns. This is in need of updating. Appropriate steps were not being taken to reduce the risk of abuse to service users. EVIDENCE: The home had not recorded any complaints since the last inspection. The Commission had overseen two complaints to the home from staff who had been employed at the home and were no longer there. The complaints were in connection to employment issues and had been investigated by the provider. The complaints procedure seen in the policy folder at inspection was in need of updating to include the address and telephone number of the Commission should service users wish to take their concerns further. The home held comprehensive policies on abuse for staff to relate to including the Whistleblowing policy. Staff spoken to at inspection were unsure of the correct steps to take should they suspect any abuse and were unsure of the Whistleblowing policy at the home. As discussed abuse awareness training should be implemented and delivered to staff who had not attended training in the past, and to remind all staff of the steps to take if they should suspect abuse. Staff recruitment was not robust and potentially put service users at risk of harm – See Staffing -Standard 29.
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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 and 26 Service users live in a homely, clean environment where they can enjoy the privacy of their own bedrooms or socialise in a variety of communal areas. There were no malodours in the home; the standards of cleanliness were very good. Infection control systems were in place. EVIDENCE: The home provides accommodation for up to thirty-seven service users within the main building, and a further five service users within the bungalows (The Barn) set in the grounds. There are two passenger lifts and a call bell system. One passenger lift had been out of action for more than 48 hours at the time of this inspection. The lift was in working order by the time the inspection was completed. As discussed a regulation 37 notice should be sent in respect of the lift being out of action; it was agreed that one would be sent to the Commission – See Management and Administration – Standard 38. Grab rails had been fitted in communal areas. There are steps between the dining room and lounge. Risk assessments are undertaken to ensure that
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 17 service users can manage these. Bathrooms had been adapted to meet service users needs. Call bells were available in all the rooms assessed at this inspection and service users told the inspector that carers answered them promptly. One radiator in a corridor was unguarded, this had been risk assessed. A wardrobe was found to be unstable, however there was no-one residing in the room at the time of the inspection. The acting manager agreed to have this secured. Service users had been encouraged to personalise their rooms and staff ensure that the privacy and dignity of service users is respected. This was evident at inspection. All service users had accessible locks on their bedroom doors. Service users spoken with informed the inspector that they were happy with their rooms. Service users had still not been provided with lockable storage for medication, money and valuables, potentially allowing access to others. As previously mentioned this had been a requirement at the last inspection and did not follow the homes policies. Equipment such as walking aids, grab rails and wheelchairs were available to assist with maintaining independence. During the inspection, service users were observed utilising the communal areas, of a quiet lounge, larger TV lounge and dining area. The cleanliness of the home was very good at this inspection. There were no offensive malodours. Hand washing facilities were now available for staff in all rooms where personal care was being given as required at the last inspection. Resources were available to aid in infection control such as aprons and gloves. All areas where hand washing facilities are available should have foot operated flip top bins provided. As discussed some areas did not have a bin available. This will be followed up at the next inspection. The laundry area was not assessed at this inspection and was found to be adequate at the last inspection. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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; 29; and 30 The home’s recruitment procedures for staff were not robust and did not fully protect service users from the risk of abuse. The skill mix of staff was appropriate to meet the needs of current service users. The staffing levels were adequate. Staff morale had improved. EVIDENCE: Two staff recruitment files of the most recently employed staff were examined. Evidence was found that the staff had commenced employment before a POVAFirst check and Criminal Record Bureau disclosure had been received. One file only contained one written reference and one verbal reference. An immediate requirement notice was issued in respect of this. Service users spoken to at inspection indicated that they felt that staffing levels were adequate at this time, and that the staff at the home could meet their needs. Duty rotas copied and given to the inspector reflected the staff on duty at the time of the inspection. Staffing levels appeared adequate to meet the dependency needs of the current service users. All staff had received induction.
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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 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): 33; 35; 36; 37 and 38. There is no registered manager at the home. Staff training was adequate. Not all staff had received specialist training. The systems in place for ensuring the health and safety of service users and staff were not adequate and put service users at a potential risk of harm. EVIDENCE: There is a management plan at the home in the absence of a registered manager. The acting manager at present is Kim Allistone who has support of Patrick and Richard Allistone. The home is actively looking to recruit a manager in the New Year and the Commission will continue to monitor the situation. The staff spoken to at inspection confirmed mandatory training to include manual handling, health and safety and fire awareness training had been provided. As discussed to meet all the needs of service users at the home
Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 20 specialist awareness training in for example dementia and diabetes should be provided to staff. Other training such as MRSA, Food Hygiene and Continence awareness had been provided. Evidence of regular staff meetings being held were seen and records had been maintained. Residents meetings had not taken place and surveys had not been implemented to allow service users to air their views on the conduct of the home and this should be developed as discussed as part of the homes internal Quality Assurance audit. This will be followed up at the next inspection. It was disappointing that action had not been taken within agreed timescales to implement all the requirements identified in the last CSCI inspection report. Some requirements have been re-issued. Staff had commenced formal supervision and records were seen at inspection. The majority of records seen at inspection were up to date and in line with current legislation, however the medication policy and complaints procedure needed revising as mentioned previously. All service records were current. The fire records were examined, the home had not conducted weekly fire checks as required by Fire Regulations according to the records and the emergency lighting had not been tested monthly. Records indicated that staff attended fire training. Door wedges and /or stools were continuing to be used to prop open door on nine bedrooms at this inspection. The service users told the inspector that they had requested that their doors be kept open. The manager had had a conversation with the local fire officer in January 2005 in regard to this and it was recommended that automatic fire door closures be provided, unless the resident was able enough to physically remove the wedges should the fire alarms sound. This must be monitored and recorded and if the service user is unable to remove the wedge, the door is either kept closed or automatic closures are fitted as required at the last inspection. An immediate requirement notice was issued in respect of this to contact the fire officer again for advice. It was noted at this inspection that fire escape doors on the corridors, which open to flights of stairs, were not alarmed. Minutes of staff meetings indicated that some service users wander at night therefore the home must ensure those doors are alarmed to reduce the risk of harm to service users. Denture cleansing tablets were seen on show in many of the en-suite facilities. Risk assessments should be carried out and the tablets stored safely to minimise any risk of harm to individual service users and others in line with COSHH Regulations. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 21 The home held some service users monies for safekeeping. A secure facility was available. Clear records were kept of any transactions and receipts were kept. Monies checked at inspection reconciled with monies held at the home. Accident records were maintained. The home had informed the Commission of any serious incidents via Regulation 37 forms. As mentioned earlier the home should inform the Commission of any incidents that may affect the service users welfare for example when a lift is out of action. The kitchen was clean, tidy and well organised at this inspection. All kitchen records were up to date. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 2 1 Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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 (2)[b] Timescale for action All individual care plans must be 15/01/06 reviewed on a regular basis to ensure current care needs are reflected. Any pressure relieving 15/01/06 equipment and wound care needs must be reflected in the individual care records. The medication policy must be 15/02/06 revised to ensure it is compatible to the procedures used at the home in line with Royal Pharmaceutical Guidelines.(Previous timescale of 30 August 2005 was not met). Also the home must follow its self-medication policy and provide lockable spaces to those service users who self mediate to ensure medicines are stored securely. The complaints procedure must 15/01/06 reflect the address and telephone number of the Commission for Social care Inspection (CSCI).
DS0000016043.V254651.R01.S.doc Version 5.0 Page 24 Requirement 2 OP8 15 3. OP9 13(2) 4. OP16 22(6)[a] Netherclay House 5. OP18 13(6) The registered person must 30/01/06 ensure that all staff are aware of the Whistleblowing policy and steps to take should they suspect abuse. Individual service users must be provided with a lockable storage area in their rooms and provided with a key to enable them to store medications, money and valuables should they wish, unless otherwise stated in the care plans and statement of purpose. (Previous timescale of 30 September 2005 was not met) All hot water outlets must have their temperature tested and records maintained on a monthly basis in line with HSE guidelines. ( Previous timescale of 06 July 2005 was not met) Staff must not commence employment at the care home until satisfactory information to include written references, a POVAFirst and CRB enhanced disclosure has been received. An Immediate requirement Notice was served in respect of this. 15/02/06 6. OP24 12(4)a& 23(2)m 7. OP25 13(4)[c] 30/01/06 8. OP29 19 Schedule 2 22/12/05 9 OP31 8 (1)[a] The registered person must 30/04/06 employ a manager for registration with the CSCI within the next 6 months. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 25 10. OP38 13(4) Fire Doors must not be propped open with door wedges or stools. The registered person must consider the provision of automatic door closures for service users choosing to keep their doors open. This will prevent risk of harm to service users should a fire occur at the home. (Previous timescale of 30 September 2005 was not met). An Immediate requirement Notice was served in respect of this at this inspection. Fire alarms must be tested on a weekly basis and emergency lighting must be tested on a monthly basis in line with Fire Safety Regulations for Care Homes. 22/12/05 11. OP38 13(4)[a] and [c] 15/01/06 12. OP38 13(4)[c] The storage of denture cleansing 15/01/06 tablets must be individually risk assessed and storage must be in line with COSHH regulations. Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 26 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. Refer to Standard OP15 OP18 Good Practice Recommendations The home should consider alternative ways of ensuring service users are aware of what is available for lunch, with special regard to those with sight problems. The home should provide all staff with abuse awareness training before the end of April 2006. Also specialist training for all staff in regard to diabetes and dementia awareness is recommended to ensure staff have the skills and knowledge to care for service users at the home. The home should commence quality assurance processes to include service user meetings and surveys by the end of April 2006 3. OP33 Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Netherclay House DS0000016043.V254651.R01.S.doc Version 5.0 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. 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!
