Inspection on 06/07/05 for Netherclay House

This inspection was carried out on 6th July 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.

Other inspections for this house

Netherclay House 01/07/08

Netherclay House 20/08/07

Netherclay House 27/11/06

Netherclay House 22/12/05

Netherclay House 26/01/05

Netherclay House 08/06/04

Netherclay House 03/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Netherclay House Bishops Hull Taunton Somerset TA1 5EE Lead Inspector Caroline Baker Unannounced 6th July 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. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Netherclay House Address Bishops Hull, Taunton, Somerset, TA1 5EE 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) 01823 284127 01823 336765 Mr Peter Howard Wilmot-Alistone Miss Sarah Jane Jeffery (nee Davey) PC Care Home only 42 Category(ies) of Old Age (42) registration, with number of places Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 26th January 2005 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 are Mr and Mrs Wilmot-Allistone. The Registered Manager is Miss Sarah Jeffery. 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. 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 D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was announced and took place on 26th January 2005. At that inspection four requirements were identified and three recommendations were made. This inspection was unannounced and took place from 09:30 hrs over one day (8 hours) by Caroline Baker. At the time of this inspection three of the requirements had been complied with and two of the recommendations had been actioned. Thirty-nine service users were residing at the home. Staffing levels were under minimum requirements during the early morning of the day of inspection. Action was taken to provide more staff from 09:30 hrs and the registered manager was assisting care staff with their care duties. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least twenty-one service users were spoken with. The registered manager was available throughout the inspection. 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. Issues raised at this inspection must be addressed within the timescales issued. Apart from these issues, it was evident that the staff are working very hard to maintain high standards of care and the inspector would like to thank the staff for their time and help during the inspection. What the service does well: Netherclay House provides a generally well-maintained, secure and comfortable environment, which meets the needs of the current client group. Evidence was seen that service users are appropriately assessed prior to admission to ensure the home can meet their needs. Service users were observed using all communal areas and appeared comfortable, happy and relaxed in their environment. Service users spoken to Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 6 stated that they liked their bedrooms and were happy and felt safe at the home. Service users were well attired and looked well cared for on the day of inspection. Service users praised the food. A choice of wholesome food was given. The food was well presented and looked appetising. Lunchtime was unhurried and relaxed. Service users told the inspector that the staff were kind, caring and always put themselves out. They knew whom to approach should they have any concerns. Individual bedrooms assessed were homely, clean and personalised. Staff training was well documented and the provision of training for staff was very good. Staff looked and acted in a professional manner. The home appeared appropriately managed by the registered manager. Staff and service users praised the support of the manager. What has improved since the last inspection? What they could do better: Evidence was not seen in the care plans sampled that service users and/or their representatives had been given an opportunity to be involved in setting up and reviewing their care plans. The medication policy must be revised, as it is not reflective of the systems used at the home. 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 seven 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. The inspector had been informed that at least eight service users and one relative had complained. Although the issue concerned was relatively minor the representative of the registered providers had poorly managed it, and no records had been kept. The registered providers oversight of the home should be reviewed. There were not enough call bells to allow all service users to summon assistance potentially putting then at risk of harm, and immediate action must be taken to rectify this. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 7 A wardrobe was found to be unstable, one private bath hot water outlet was found to be running above Health and Safety (HSE) guidelines and one radiator outside a bedroom had not been guarded. All these potentially put service users at risk of harm. On assessment of the premises it was noted that hand washing facilities for staff had not been provided in the majority of rooms where personal care was provided. To control infection these facilities must be provided. At the last two inspections it has been recommended then required that sitting scales be provided to allow those service users with poor mobility to be weighed. These had not yet been provided and must be to monitor service users weights effectively to allow action to be taken should a loss of weight occur. All employed staff should have a contract of employment. The four recruitment files examined did not contain a contract. Staff confirmed non-receipt of contracts. 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 D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 8 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 Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 9 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) 1, 3, 4, and 5. NMS 6 is not applicable to the home. Prospective service users are provided with information to allow them to make an informed choice. The home takes appropriate steps to ensure the needs of prospective service users can be met prior to a decision being made about admission. EVIDENCE: A Statement of Purpose and Service User Guide was available. Service users confirmed receipt of a service user guide to the home. Evidence was seen in the four care records examined that a full pre-admission assessment had been undertaken to ensure the home could meet individual service users needs prior to admission. It was evident that the staff individually and collectively had the skills and experience to deliver the services and care which the home offers through staff files examined and training records seen. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 10 Some service users spoken to confirmed that they had been able to visit the home prior to admission. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, and 10. EVIDENCE: Each service user had an individual plan of care. The home’s care planning system demonstrated that care plans were kept under review. Service user input to their care plans was not reflected as recommended at the last inspection. Service users have access to health care professionals expertise to meet their individual needs. District Nurses were attending two service users at the home who had pressure ulcers and two requiring wound dressings. Only service users able to stand had been weighed. As recommended in June 2004 and required in January 2005 sitting scales must be provided to enable effective assessments to be carried out should service users become frail with loss of weight. Service users were protected by the homes procedures in regard to the receipt, administration, recording and disposal of medications. The medication policy however needs revising. Self-medication was actively encouraged however storage was not provided as stated in the self-medication policy. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 12 Service users were treated with kindness and respect. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, and 15. Service users benefit from a range of activities provided by the home to suit their individual choices and needs. The home is open to visitors at any time and encourages service users to access the local community. Service users individual choices and needs dictate the routine of the home. Service users are offered a choice of nutritious well-balanced menus promoting their health and well-being. EVIDENCE: Activities such as craftwork, reminiscence, flexercise, quizzes, bingo, aromatherapy and word games are offered to all service users at least weekly. The home has its own mini bus with a dedicated driver. Trips are organised regularly. Service users spoken to felt that the activities on offer were adequate for their individual needs. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 14 The home has a visitor’s book, which indicated visitors to the home at varying times. Service users told the inspector that their families and friends were made welcome at the home and always given refreshments. Relatives spoken to indicated their satisfaction with the care provision at the home. It was evident through comments received from service users that they had a choice of daily living. The inspector was able to observe service users during their lunchtime meal. The meal looked appetising and was well presented. All service users spoken to stated that the food was good. The majority of service users in dining room appeared to enjoy their meals. The atmosphere was happy and unhurried. Although a choice is not given at lunchtime service users told the inspector that an alternative is available; it is recommended that this be recorded on menus to enable service users to know what they are having and be able to choose. Menus do not reflect what is available for supper however a choice is given and staff ask service users on a daily basis what they would like. Service users confirmed this. The main cook had left the day before the inspection and a cook from an agency was in place. The inspector spoke to the agency cook who appeared organised and stated that they had enjoyed working at the home. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 standard(s) 16, 17 and 18. A complaints procedure is made available to service users to allow them to raise any concerns. Appropriate steps were being taken to reduce the risk of abuse to service users. EVIDENCE: The complaints procedure is found within the statement of purpose, which is given to each service user. All service users spoken to stated that they had no complaints and would know whom to speak to if they did. A complaints record is kept and the home had not recorded any complaints since the last inspection. Staff informed the inspector that service users and a relative had complained recently about margarine being served instead of butter on their breakfast trays as always was. These complaints had not been recorded therefore outcomes were unclear. All complaints should be recorded and acted upon in line with the homes complaints policy. All staff before commencing employment at the home had a POVAfirst check as part of an enhanced CRB disclosure for the protection of vulnerable service users at the home. Four recruitment files sampled evidenced this. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 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. Service users were unable to lock away medication, money or valuables in their own rooms. Service users had access to specialist equipment where there was an assessed need however there was a shortage of call bells which compromised the safety of service users. There were no malodours in the home; the standards of cleanliness were generally good. Infection control systems needed improving. EVIDENCE: All communal areas and at least fourteen bedrooms were seen at this inspection. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 17 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. Grab rails had been fitted in communal areas. There are steps between the dining room and lounge. Risk assessments are undertaken to ensure that service users can manage these. Bathrooms had been adapted to meet service users needs. One service user was without a call bell, preventing them from summoning assisitance, which led to an immediate requirement being issued. One radiator in a corridor was unguarded, a hot water outlet ran at 50oC, and a wardrobe was found to be unstable putting the service users at risk of harm, this also led to an immediate requirement being issued. 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 not been provided with lockable storage for medication, money and valuables, potentially allowing access to others. 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. Some were enjoying the garden. The cleanliness of the home was very good at this inspection. There were no offensive malodours. Hand washing facilities were not 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. The laundry area was clean and well organised with sufficient equipment to enable the smooth running of the laundry. Service users told the inspector that their laundry was always well attended to. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 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, and 30. The home’s recruitment procedures for staff were robust and protected service users from the risk of abuse. The skill mix of staff was appropriate to meet the needs of current service users. The numbers of staff were inadequate. Staff morale was generally good though unsettled by recent events. EVIDENCE: As part of the inspection process four staff recruitment files were sampled and examined. All contained documentation, apart from staff contracts, required by legislation for the protection of vulnerable adults. 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. Staffing levels were inadequate on the morning of inspection. The registered manager was undertaking care duties two senior carers were on duty with one carer from 07:30 and a further carer arrived at 09:30 hrs. The cook had left the day before and a further kitchen assistant had been asked to leave the evening before by the provider’s representative. One carer was off sick and another did not turn up. This potentially put service users health and safety at risk when staffing levels were low from 07:30. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 19 Staff spoken too told the inspectors that staffing levels were normally very good and that the day of the inspection was unusual. Agency staff were used to cover the shortfalls to include the cook during the morning and care staff during the afternoon. The CSCI should be informed of any shortfalls and difficulties when they arise as it could compromise the provision of care at the home putting service users at risk to their safety. Considering the shortfalls the inspector was pleased to see the effort put in by all the staff on duty to ensure the care of the service users was not compromised. Staff morale although generally good was unsettled due to recent events at the home, and the CSCI will continue to monitor this. Copies of duty rotas given to the inspector indicated that minimum staffing levels had been maintained over the past two weeks up until the day of inspection. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 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, 32, 34, 36, 37 and 38. The registered manager effectively manages the home. The home is committed to staff training. The systems in place for ensuring the health and safety of service users and staff were not adequate. EVIDENCE: There had been no changes to the management of the home. Sarah Jeffery continues to effectively manage the home. Service users and staff spoke highly of the manager. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 21 It was evident having spoken to staff and service users on the day of inspection, that the manager communicates a clear sense of direction, and leads the staff in a way that they understand. A recent staff meeting covered many issues. Action had been taken within agreed timescales to implement all but one of the requirements identified in the last CSCI inspection report. The Employers liability Insurance was displayed in the entrance hall with an expiry date of 1st November 2005. Staff had commenced formal supervision and records were seen at inspection. The registered manager however had not received any formal supervision since commencement of her employment in September 2004. Following a lengthy discussion with the manager it appeared that some formal supervision would benefit the manager to allow her to feel supported and valued. The records seen at inspection were up to date and in line with current legislation, however the medication policy and self-medication policies need revising as mentioned previously. All service records were current. The fire records were examined, the home conducts weekly fire checks. The emergency lighting is now tested monthly inhouse as required at the last inspection. Records indicated that staff attended fire training. Door wedges were being used on several occasions to prop open service users bedroom doors. 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. One wardrobe was identified as not being safe at this inspection, a hot water outlet was running very hot water from a bath and a radiator was unguarded as previously mentioned. Accident records were maintained. COSHH records were maintained. The home has informed the CSCI of any serious incidents via Regulation 37 forms. The kitchen was clean, tidy and well organised at this inspection. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 1 3 2 2 2 STAFFING Standard No Score 27 3 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 2 3 3 3 3 x 4 x 2 2 1 Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 23 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 OP7 Regulation 15(2)[c] Requirement Evidence must be demonstrated that service users whenever capable, and/or their representatives have input into the drawing up of their care plans. The registered person must supply weighing scales suitable for service users with poor mobility ( a previous recommendation on 8 June 2004 and requirment with a 6 month timesacle on 26 January 2005 had been issued) The medication policy must be revised to ensure it is compatible to the procedures used at the home in line with Royal Pharmaceutical Guidelines. All complaints must be recorded and investigated and records of action taken by the registered person maintained. Call bells must be provided in every room accessible by service users (an immediate requirment notice was issued). Individual service users must be provided with a lockable storage area in their rooms and provided with a key to enable them to Timescale for action 30 August 2005 2. OP8 12(1)[a] [b] and 16(2)[c] 30 July 2005 3. OP9 13(2) 30 August 2005 4. OP16 17(2) Schedule 4 (11) 12(1)[a] and 13(4)[c] 12(4)[a] and 23(2)[m] 30 July 2005 06 July 2005 30 September 2005 Page 24 5. OP22 6. OP24 Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 7. OP25 13(4)[c] store medications, money and valuables should they wish, unless otherwise stated in the care plans and statement of purpose. All hot water outlets must be tested and records maintained on a monthly basis and action taken when temperatures are above HSE guidleines of 4344oC. All radiators must be guarded and/os risk assessed in line with HSE guidleines. An immediate requirment notice was issued. Hand washing facilities must be provided for staff in all rooms where personal care is provided in line with infection control guidelines. All staff must be provided with a contract of employment. Fire Doors must not be propped open with door wedges. The registered person must provide 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. 06 July 2005 8. OP26 13(3) 30 July 2005 9. OP29 10. OP38 17(2) Schedule 4 (6)[d] and [e] 13(4) 30 July 2005 30 September 2005 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 OP12 Good Practice Recommendations An individual activities folder which reflects a detailed timetable of activities accessed and the outcomes for D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 25 Netherclay House 2. 3. 4. OP15 OP36 OP33 service users should be maintained. Menus should reflect an alternative choice at lunchtime and a supper menu should be recorded and be made available for service users. The registered provider should ensure that the registered manager receives formal supervision and appraisal at least 6-monthly. The registered providers oversight of the home should be reviewed. Netherclay House D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53-D02 S16043 Netherclay V226776 060705 Stage 4.doc Version 1.30 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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