Inspection on 06/01/06 for Ogilvy Court

This inspection was carried out on 6th January 2006.

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

Ogilvy Court 07/08/07

Ogilvy Court 15/11/06

Ogilvy Court 21/06/05

Ogilvy Court 25/02/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE Ogilvy Court 13-23 The Drive Wembley Park Wembley London HA9 9EF Lead Inspector Unannounced Inspection 6th January 2006 10:45 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 Ogilvy Court DS0000059961.V277336.R01.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. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ogilvy Court Address 13-23 The Drive Wembley Park Wembley London HA9 9EF 020 8908 5311 020 8908 5807 manager.ogilvy@careuk.com 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) Care UK Mr Mark Morray Adjorlolo Care Home 57 Category(ies) of Dementia - over 65 years of age (45), Learning registration, with number disability (12), Learning disability over 65 years of places of age (12), Mental Disorder, excluding learning disability or dementia - over 65 years of age (45) Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user category LD is to include only service users of age 45 and over. 21st June 2005 Date of last inspection Brief Description of the Service: Ogilvy Court is a care home, which belongs to Care UK, a national care homes provider. It is situated in The Drive, which is a small road off the main busy Forty Lane. It is easily accessible by buses, which pass on the main road and is about 5-10 minutes walk from local shops and local amenities. It is a short bus ride journey to Wembley town centre. It also has a large car park in front of the home easily accommodating about fifteen cars. Ogilvy Court is a care home specialising in providing nursing care for elderly service users over the age of 65 years with mental illness and for service users with a learning disability from 45 years of age. It is purpose built and provides accommodation in mostly single rooms with en-suite facilities. It has three double bedrooms also with en-suite facilities. There are three units in the home. Ivy accommodates twelve service users with a learning disability, Dahlia accommodates fifteen male elderly service users with mental health needs and Bluebell accommodates thirty mostly female elderly service users also with mental health needs. The management structure in the home normally consists of the manager and three unit managers. The home provides all the other necessary ancillary services such as laundry and catering. At the time of the inspection, there were fifty-one service users in the home. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second of the statutory inspection for the period 2005-2006. It was unannounced and started on the 6th January 2006 at 10:45-16:00 and continued on 9th January at 10:15-16:30, lasting a total of about eleven hours. The registered manager was not in the home during the inspection and the inspector had the opportunity to meet Leona Skidmore, a support manager from Care UK, who was in charge of the home at the time. During the course of the inspection, the inspector talked to visitors in the home, some service users, the support manager and some members of staff. He also looked at a sample of records, which the home has a statutory duty to keep, toured some of the premises and checked for compliance with past requirements and recommendations. The inspector would like to express his thanks to Leona Skidmore for her support and assistance during the inspection. He would also like to thank all those who contributed to the inspection, including visitors to the home, service users, all the unit managers and their staff. What the service does well: What has improved since the last inspection? The needs assessment of service users has improved slightly, but as mentioned below could be further improved. While the content of records, kept by the home, has improved to some extent, there is room for further improvement. There was evidence that there has been an increase in the involvement of service users or of their relatives in the care planning process. Menus are reviewed at least four weekly when the chef reprints the menu sheets, to address the dietary needs of service users. Ogilvy Court DS0000059961.V277336.R01.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. Ogilvy Court DS0000059961.V277336.R01.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 Ogilvy Court DS0000059961.V277336.R01.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 and 3 The service users’ guide and other documents accessible to service users are available in format suitable for the needs of service users, upon request. The home has a range of documents describing the terms and conditions, which will be given to service users according to their individual circumstances of funding. The standard of the assessments of the needs of some service users has improved slightly, but were not as comprehensive as they could have been. The assessment of the mental health needs of service users was also lacking. As a result there is a possibility of not identifying all the needs of service users in a comprehensive manner. EVIDENCE: With regard to the format of the service users’ guide and other documents accessible to service users, the support manager stated that the SUG is now printed in big print and that there is a note attached to say that requests can be made for the SUG in other formats which would then be obtained from the Head Office of Care UK. During the last inspection the inspector noted that all service users, irrespective of the type of funding received the same terms and conditions. On Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 9 this occasion a number of formats of the terms and conditions of stay in the home representing the different sources of funding of the placements were seen. The support manager stated that she was in the process of ensuring that each service user receive the terms and conditions, which best reflect their individual circumstances. The inspector looked at four care plans as part of tracking the care of some service users. He noted that the needs’ assessments of service users were completed to varying degrees. There has been some progress as some care records contained good assessments of the physical needs of service users but some were not so comprehensive as the different sections of the assessment were not always fully completed. For example the section of the assessment of one service user’s needs dealing with communication only addressed the verbal aspect of communication and did not address non-verbal communication, whether the person can hear and understand appropriately and the person’s disposition to communication. The section on eating did not always described the like and dislikes of the service user and the section on sexuality for another service user said that ‘he does not express any’. The mental health needs of service users were lacking. Apart from a version of the Mini-Mental Scoring, there was no comprehensive assessment of the needs of service users with regard to mental health and psychological needs. As a result of the above the inspector assessed the standard as almost met. Ogilvy Court DS0000059961.V277336.R01.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): 7-10 The care plans in a few cases were not reviewed monthly. As a result there is no possibility to verify if the care plans were appropriate to meet the needs of service users. Service users health care needs were met in most cases. However there were no consistent records to show that service users were seen at least yearly by the dentist and optician. The management of medicines in the home continue to be of a good standard. While service users were addressed and treated appropriately by staff, a few issues were identified which could undermine the good work that is normally done with regard to maintaining the privacy and dignity of service users. EVIDENCE: All care records were tidy and in good order. They were all kept in the nurses’ offices. The inspector was informed that the home was in the process of transferring all care records into computerised records. Plans of care for the identified needs of service users were generally comprehensive. Reviews of care plans were generally monthly, but in some cases this was not carried out, particularly in November and December. This was apparently linked to a shortage of staff around that time. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 11 There was evidence that staff had made attempts to involve service users or their representatives in drawing care plans. In cases where this was not possible, there were records to explain why this was not possible. The home must now build on progress already achieve in this area and involve service users/representatives not only in drawing the care plans but also in the review of these. All service users were registered with a GP. There was evidence that service users were seen by other healthcare professionals and that service users were referred to the relevant healthcare specialists when that was necessary. There was however a lack of records to demonstrate whether service users were seen at least annually by the dentist and the optician. The home uses the Waterlow score to assess service users’ risk of developing pressure sores. Service users who were identified at risk had pressure relief equipment in place. However in the case of at least two service users who had pressure relief equipment, the care plan did not describe the pressure relief equipment that was in place for them. The care records of one of the service user mentioned that there was a small pressure sore. There was however no care plans in place dealing specifically with the sore. The inspector was also unable to see photos, wound mapping or wound tracing of the sore. It is essential that appropriate records are kept as evidence that service users are receiving appropriate pressure area or wound care. All service users had a continence assessment and a care plan addressing any needs identified in relation to continence/incontinence. There has been some improvement in the content of these assessments and in the care plans addressing the promotion of continence and management of incontinence. Of the four care plans inspected, two were quite descriptive about addressing the needs of the service users, but the other two were not so descriptive. They contained terms such as ‘toilet regularly’; use ‘appropriate incontinence pads’; and ‘develop optimum bladder/bowel control’. As a result there was not enough records to show that all service users were being appropriately cared for with regard to incontinence/continence. Service users in the main were appropriately dressed and seemed to benefit from a good standard of personal hygiene. Male service users were appropriately shaved and groomed. The inspector noted that all personal care and nursing interventions were offered in the bedrooms of service users or in private. He however did note that a number of clothing items for service users were not ironed appropriately. These included a number of jumpers/tops for female service users, and shirts and trousers for male service users. As mentioned in the previous report, this detracts from the good care that the home otherwise provides. The support manager was very aware of the problem and she stated that she was in the process of recruiting a laundry assistant. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 12 The home has replaced the call-bell system. However the inspector noted that very few service users were offered the call bells. There may very well be reasons for this such as when there is a risk of ligatures. There should however be a recorded risk assessment in these cases as per schedule 3 of the Care Homes Regulations 2001. The home has a trolley phone, which could be plugged in a number of areas in the home. This can then be wheeled to the bedrooms of service users. Unfortunately this is not accessible to all the bedrooms in the home. The support manager was aware of the problem and she stated that she has been considering a number of options to provide this facility to service users, including the acquisition of a cell phone. The inspector checked the management of medicines on the Daffodil and Ivy units. He sampled a number of medicines charts randomly, looked at the storage of medicines and inspected the records about receipt and disposal of medicines randomly. Medicines received into the home were recorded on a special sheet. This was checked randomly and was appropriately completed in most cases, except for an antibiotic when the amount received into the home was not entered on the record sheet. There were no gaps on the medicines charts showing that members of staff have appropriately signed when they have administered medicines or used a code if the medicines were not given. The home has a contract with a waste carrier for the disposal of medicines. The inspector was informed that the home has requested a special disposal unit for controlled drugs, which was expected in the home. The knowledge of staff responsible to administer medicines with regard to medicines was good. Issues identified during the last inspection with regard to the monitoring of the serum level of service users who were on certain medicines and having a protocol/individual care plan for all service users who were on rectal diazepam, have been addressed. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 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 and15 The home provides suitable recreational and social activities to service users, but records must be more comprehensive to evidence this. Meals provided by the home are varied and appealing. These are served in a congenial and pleasant environment. EVIDENCE: The home has a number of activities coordinators who are allocated to the various units. They are responsible for organising and carrying out social and recreational activities with service users. The social and recreational needs of service users were assessed and recorded in the care records. Some service users had a plan to address the identified needs and some did not. There were also records about the actual social and recreational activities that service users have taken part in. These in some cases were up to date but in other cases were not. There was therefore a need to ensure more comprehensive records with regard to the social and recreational needs of service users. The home continues to have a four weekly menu cycle, which is reviewed and updated every four weeks. There were dates on the menu and staff could easily point to the menu, which was on offer for that day. Meals were served in the dining rooms in a congenial and relatively pleasant environment. The inspector observed that service users were offered support in a sensitive and appropriate manner. Service users receive three meals a day and a snack in Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 14 the evening. There were comprehensive records of the main meals (lunch) cooked in the home but not of the suppers and of the snacks served in the evening. The chef stated that she would be keeping a record of these meals as well. The inspector concluded that the catering department has made efforts to improve the service that it offers. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 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 Complaints are taken seriously by the service and are dealt with in an appropriate manner. EVIDENCE: The registered manager sent copies of a complaint to the inspector. The complaint was then withdrawn by the complainant. This however showed that the home took the complaint seriously and had an open approach to addressing the complaint. The complaint procedure is provided to service users in the service users’ guide and the support manager stated that this is also available in other formats upon request. Ogilvy Court DS0000059961.V277336.R01.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, 24 and 26 The home did not have a comprehensive redecoration and refurbishment plan. As a result there is no guarantee that the home will continue to provide a safe and quality environment for service users. Some issues with regard to infection control were identified which could put service users at risk. EVIDENCE: The grounds in front of the home were being tidied at the time of the inspection. This was in keeping with the time of the year, but the edges could have been trimmed to give a neater and more attractive appearance to the front of the home. The exterior of the building was generally in good order. The home did not have a redecoration and refurbishment plan at the time of the inspection. This had been a requirement following the last inspection in the home. Since the last inspection some areas have been redecorated. However the home has been opened for about 9 years and it therefore needs a sustained input to maintain the quality of its environment, furnishings and fittings to a high standard. Some areas were looking tired and needed redecoration. This would also apply to the carpet in the communal areas and in Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 17 the bedroom of service users, which looked stained and dirty in places. The bell at the entrance of the home was broken and had been taped. It did not inspire confidence to use it. A shower on the Ivy unit was in poor condition and looked very unattractive. It smelled of damp, there were marks on the walls and needed to be redecorated/retiled. The support manager was however open and transparent about the various redecoration and refurbishment issues that needed to be completed in the home and of the need to have a comprehensive plan to address these issues. She has also been carrying monthly visits as per Regulation 26 and had identified the above issues in her reports. Although the carpet in some bedrooms needed to be shampooed/replaced and the general state of decoration in some bedrooms needed improvement, some of the bedrooms continue to be personalised to a high standard. The personalisation of the bedrooms is indeed commendable and is an example of good practice, while the state of decoration of the bedrooms needs to be attended to. The inspector identified some practices with regard to infection control, which needed improvement. This included a suction tube, which was washed and reattached to the suction machine for reuse; gloves being found in a small bin in one bedroom; the absence of any anti-bacterial hand wash or alcoholic hand rub in the bedroom of one service user who has been identified with a particular infection; and the absence of a spillage kit or anything to that effect which can be appropriately used to deal with spillages of body fluids. The home uses individual lancing devices for those service users who need blood sugar testing. The lancing devices were however of the type to test on self and not for professionals to use for testing the blood sugar of service users as per the Medical Device Alert, MDA/2004/044. The inspector also noted that the legs of a hoist, which was being used for bathing/showering service users, were covered with lime scale. As a result of the findings in the last paragraph the inspector concluded that there were a few infection control issues, which needed to be addressed. Ogilvy Court DS0000059961.V277336.R01.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): 28 and 30 The home had adequate numbers of staff to care for the service users. There was evidence that some of the training needs of staff were being addressed, but not all staff have had the necessary statutory training. A training and development plan is required to ensure that staff maintain and continuously improve their expertise to care for the service users in a safe and appropriate manner. EVIDENCE: The home had adequate numbers of staff on duty on each unit during both days of the inspection. The inspector was informed that the month of December was a difficult month with regard to ensuring that the home was fully staffed. The problem was exacerbated by the holiday period, but this has now been resolved. The home uses its own staff most of the time and only uses agency staff when this is necessary. The support manager stated that the agency, which is used by the home, has been requested for proof of CRB checks for all staff sent to the home and of PIN checks for trained nurses. Training with regard to NVQ level 2 continues to progress. 25 members of staff were in the process of completing the course. No new members of staff have enrolled on a course, but the inspector was informed that a number of staff has been identified to enrol on the course when it will be provided next. Apart from NVQ training a number of staff have received training in areas such as ‘managing aggressive behaviour’, ‘First Aid’, ‘incontinence’, Learning disability awareness’ and ‘diabetes’. The inspector was kindly provided with a Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 19 list of staff training records with regard to statutory training. He noted that most staff have had Fire Training, and a that a significant number have not received food hygiene, health and safety, manual handling, infection control and abuse training. A training and development plan addressing the training needs of staff in the home, had however not been forwarded to the inspector. While there is evidence of training taking place in the home, such a plan would have supported a judgement about the standard of training in the home. Ogilvy Court DS0000059961.V277336.R01.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): There was appropriate management support in the home at the time of the inspection. The organisation takes quality issues seriously and has systems in place to deal with these. Most health and safety issues are being addressed appropriately in the home. The electrical wiring certificate had not been renewed since the last inspection. EVIDENCE: The registered manager was not in the home at the time of the inspection. Management support was being provided by Leona Skidmore, a support manager for Care UK. She has previously worked as a Home manager for Care UK for more than eight years. She was able to demonstrate clearly that she was familiar with issues in the home and with the relevant legislation and minimum standards, which apply to Ogilvy Court. She had arranged a number of meetings with staff, one of which was witnessed by the inspector. Minutes of Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 21 some of the meetings were available for inspection. All staff, who spoke to the inspector, said that they were being appropriately supported by management. The home has a quality control policy. The support manager said that the organisation now has devised satisfaction questionnaires. Some would be left in the reception area for visitors/stakeholders to complete. The organisation has a clinical governance section, which is in charge of quality control issues in the homes and in carrying audits. The home did not have a development plan in place at the time of the inspection. A development plan would look at further improvement of the home and of the service that it provides to the service users. The support manager stated that the home has not been able to maintain its programme with regard to ensuring that all care staff have supervision at least six times a year. She said that she has plan to build on progress which has already been achieved and improve the supervision process in the home. The home did not have an up to date wiring certificate, but a letter confirmed that a date has been booked to carry out that test. A copy of the certificate must be sent to the local CSCI office once the test has been carried out. There was evidence that some members of staff have recently taken part in a fire drill. Fire training in the home was mostly up to date. The inspector was shown the format of a comprehensive fire risk assessment, which was going to be individualised for the home. The support manager stated that she was setting up Health and Safety Committee to look at the health and safety issues in the home. Ogilvy Court DS0000059961.V277336.R01.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 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X 2 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Ogilvy Court DS0000059961.V277336.R01.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 OP3 Regulation 14(1,2) Requirement Timescale for action 31/03/06 2. OP7 15(2)(b) 3. OP8 12(1) 4 OP8 15(1,2) The registered person must ensure that all service users have a thorough assessment of their needs including their mental health needs (Previous requirement, timescale of 15/9/05 not fully met) The registered person must 31/03/06 ensure that all care plans are reviewed at least monthly (Previous requirement, timescale of 15/9/05 not fully met) The registered person must 31/03/06 ensure by training of staff or otherwise that the pressure relief equipment in use is described in the care records as evidence that appropriate pressure area care is being provided for service users. There must also be comprehensive records about pressure sores including the use of wound mapping/tracing and photographs. (Previous requirement, timescale of 15/9/05 not fully met) Care plans and continence 31/03/06 assessments must make clear DS0000059961.V277336.R01.S.doc Version 5.1 Ogilvy Court Page 24 5 OP8 13(1)(b) 6 OP10 12(4)(a) 7 OP10 16(2)(a) 8 9 OP10 OP12 17(1)(a) 16(2) (m,n) 10 OP24OP19 16(2)(c) the steps being taken to promote continence and the type of pads being used to manage the incontinence and the times for changing the pad (Previous requirement, timescale of 15/9/05 not fully met). The registered person must ensure that all service users are seen by healthcare professionals such as the dentist and optician at the required intervals with records being made about the outcomes of these visits. (Previous requirement, timescale of 30/9/05 not met) The registered person must ensure that the clothes of service users are always ironed appropriately. (Previous requirement, timescale of 15/9/05 not met) The home must have a facility to enable service users to make or to receive phone calls from the privacy of their bedrooms, in cases where service users are unwell or confined to their beds. (Previous requirement, timescale of 15/9/05 not fully met) Service users must be offered a call bell unless there has been a documented risk assessment. The registered person must ensure that comprehensive records, including a care plan, are kept about the social and recreational needs of service users. The home must have a redecoration and refurbishment plan with records being kept of areas/issues, which have been addressed (Previous requirement, timescale of 15/9/05 not fully met). DS0000059961.V277336.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Ogilvy Court Version 5.1 Page 25 11 OP26 13(3) 12 OP30 18(1)(c) 13. OP36 18(2) 14. OP38 13(4) The registered person must ensure either by training or otherwise that the following infection control issues are addressed: • Ensure that all suction tubes are discarded after use • Ensure that there are appropriate antibacterial hand wash/rub in the home • Appropriate lancing devices are used for the blood testing of service users who are diabetic. • Ensure that there are appropriate facilities in the home, such as spillages kit, to clean the spillages of body fluids. • Ensure that the legs of the hoists are clean and free from lime scale The home must have a comprehensive training and development plan. (Previous requirement, timescale of 30/9/05 not fully met) There must be supervision of staff every two months or at least six times a year. (Previous requirement, timescale of 30/9/05 not fully met) The registered person must ensure that there is an electrical wiring certificate in place for the home and must forward a copy to the Local CSCI office when this is completed (Previous requirement, timescale of 15/9/05 not fully met) 31/03/06 31/03/06 31/03/06 15/03/06 Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 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. Refer to Standard OP33 Good Practice Recommendations The home should have an annual development plan based on a systematic cycle of planning-action-review, reflecting the aims and outcomes for service users. Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Ogilvy Court DS0000059961.V277336.R01.S.doc Version 5.1 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. 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