Inspection on 06/02/07 for Olive House

This inspection was carried out on 6th February 2007.

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

Olive House 03/10/07

Olive House 06/02/06

Olive House 05/09/05

Olive House 06/12/04

Olive House 12/08/04

Olive House 15/12/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Olive House New Line Bacup Lancashire OL13 OBT Lead Inspector Mrs Christine Mulcahy Key Unannounced Inspection 10:00 6th February 2007 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 Olive House DS0000036431.V302684.R01.S.doc Version 5.2 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. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Olive House Address New Line Bacup Lancashire OL13 OBT 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) 01706 873322 Lancashire County Care Services Mrs Doric Hilda Davis Care Home 44 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (9), Old age, not falling within any other of places category (29), Physical disability (6), Physical disability over 65 years of age (6) Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 44 service users to include: Up to 29 service users in the category of OP (over 65 years of age, not falling into any other category) requiring personal care Up to 9 service users in the category of DE(E) (Dementia over 65 years of age, not falling into any other category) requiring personal care. Up to 9 service users in the category of DE ( Dementia, under 65 years of age, not falling into any other category) requiring personal care Up to 6 service users in the category of PD(E) (physical Disability, over 65 years of age) requiring personal care Up to 6 service users in the category of PD (Physical Disability, under 65 years of age) requiring personal care Date of last inspection 6th February 2006 Brief Description of the Service: Olive House is a large detached building set in it’s own grounds. It is part of Lancashire County Care Services and is registered with the CSCI to provide personal care and accommodation for up to 40 older people. There are 4 separate living units that have different functions and provide different levels of care. Due to previous building and refurbishment work each of the 4 units are now homely and cosy environments to live in. A new building extension provides service users with a spacious dining area, lounge, conservatory, and modern garden decking that overlooks the local bowling green. Many bedrooms are en suite and there are assisted bathrooms, shower rooms and toilets for service users throughout the home. The service also operates a rehabilitation unit for 6 service users and this is separately staffed. A well-attended day service is situated in the building. Olive House is located on New Line Road close to local shops, a library and other amenities in the town centre of Bacup. It is situated on a main bus route that offers transport to all towns in the Rosendale area. Prospective service users receive a copy of the homes service user guide and have access to the Statement of Purpose. Fees range from £324 - £366 per Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 5 week. Service users are billed separately for hairdressing, newspapers and toiletries. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, including a visit to the home took place over 2 days on 6th and 9th February 2007. Information was obtained from service user care plans, staff records, management systems, observations of care practices service user and relative questionnaires and policies and procedures. The inspector also spoke to 5 service users, 4 staff, 3 relatives and the registered manager. What the service does well: What has improved since the last inspection? What they could do better: There has been some progress towards meeting some of the requirements made at the previous inspection. However the health and safety and wellbeing of service users should be clearly identified in each care plan and include risk assessments where the risk is greater. Where possible service users should be consulted about the details of care and this information should be included in the care plan. The information would then be accurate and current and should tell staff exactly how to meet these needs. Because there are some times when there are no staff immediately available to help service users, staff ratios must be determined according to the assessed needs of service users. Additional staff must be on duty at peak times of Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 7 activity during the day to reflect service user need and the layout of the home. Where staff ratios are not sufficient staff cannot fully meet service user needs On one unit medication is potted up to save on staff time and the homes medicines policy and procedure is not being followed. This means that service users are at risk of mis administration. A broader range of activities available to service users are limited. There should be greater effort by the staff team to make sure that the amount of social and recreational input is increased as the lack of meaningful activity reduces service user quality of life. Activities like books or magazines left on tables, and regular visits to places of interest would encourage more therapeutic activity within the service user group. The arrangements for health and personal care must ensure that service user privacy and dignity is respected at all times and care tasks should always be recorded in the service user care plan not on reminder notes on service user bedroom walls. In order to maintain service user appetite and nutrition liquified meals must be presented in a manner that is attractive and appealing in terms of texture, flavour and appearance. Group living settings highlight the domestic aspects of life and are more easily understood by people with dementia. However the patterned carpet in the communal area highlights a lack forethought and should be re assessed by a suitably qualified person with specialist knowledge of the service user group. This is so it can be shown that the carpet needs to be changed to a more helpful design feature and is more appropriate to the needs of the service users on the unit. 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. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Olive House DS0000036431.V302684.R01.S.doc Version 5.2 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 the following standard(s): OP 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are admitted following a full assessment so that staff know what their needs are. Care plans are based on these assessments. Intermediate care helps to maximise their independence and return home. EVIDENCE: Two service user care plans were examined and showed that the registered manager had carried out a needs assessment before the service user moved into the home. The assessment documentation was always available to staff on the rehabilitation and residential units. This helped familiarise them with the new service user. One staff spoken to was aware of the need for service user assessments and knew that these formed the basis of the care plan. There was a dedicated space for the rehabilitation facilities. Staff from relevant professions met the assessed needs of service users admitted for rehabilitation. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 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): OP 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all service user care needs were set out in plan of care. Service users were not protected by the homes medicine policies and procedures and were at risk of harm from mis administration. Not all care practiced observed showed service users privacy and dignity was respected. EVIDENCE: Case tracking and discussion with the registered manager confirmed that all service users had a care plan and these were reviewed in February 2006. Care plans seen lacked personal history detail and none of the care plans contained a photograph of each service user. This means that new staff would not be able to properly identify service users. Care plans viewed did not included sufficient details for staff to meet those need identified and did not detail how identified needs would be met this meant that their personal and health care needs couldnt be met properly. One care plan examined did not include information about the service users dietary needs and that his meals should be liquidised and thickener added to Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 11 his drinks. Discussion with the service user showed poor oral hygiene and there was no mention in his care plan of the need to promote good oral hygiene. Another care plan stated that service users had been involved in drawing up plan but had not been signed by the service user. When 2 service users were asked if they had been involved in drawing up their care plan they said they had not. One relative confirmed that she had not been involved in drawing up her mothers care plan. Risk assessments seen were not signed or agreed by service users or their relatives. Because this was not confirmed this meant that service users did not know if the identified needs were accurate and staff could not be certain they were fully meeting service user needs. Another care plan examined although limited in some information contained a falls risk assessment and included a risk assessment for the use of a crash mattress, and a night care plan containing a 4 hourly turn record sheet. Nine service users were seen to be using a pressure relieving mattress or cushion but this was not indicated on the care plans. Care plans in the main were not person centred and did not recognise the diverse needs of some service users. The home has a mecdication policy which is accessible to staff. On one of the units medicines were potted up prior to adminstering. It was noted that none of the service user Medication Administration Record sheets (MAR) contained photographs of service users. There was no risk assessment for service users who self medicated. MAR sheets recorded Daktacort cream prescribed for a service user but the cream could not be located. The registered manager said that the service users wife usually brought Conatrane. However this was not written on the MAR sheets. Some MAR sheets had not been signed regularly and the medicines trolley was over stocked with medication. Medicines received and disposed of were recorded. The registered manager said she would contact the supplying pharmacist to carry out a medication audit. The medicine trolley on one unit contained 3 bottles of sherry belonging to a service user. The care staff commented that they belonged to a service user who liked a regular drink. The inspector advised this should be removed immediately and stored appropriately. Out of 33 care staff 30 have been trained in the safe handling of medicines (SHOM). Access to other health professionals was given and evidence of district nurse, chiropody and ophthalmic services were seen. Health and personal care arrangements ensured service user privacy. Evidence seen confirmed that service users health is monitored and professional advice on health care issues is sought and acted on. Aids and equipment necessary to promote service user wellbeing were seen in use in the home. A tour of the home showed a number of bedrooms had notices pinned on the walls to remind staff to carry out tasks to service user. This meant that service users privacy and dignity was not respected. The registered manager was reminded that care instructions must be included in the service user plan of care at all times. When asked about the clothing they were wearing service users confirmed that clothing worn that day was their own and clothing seen in wardrobes were named accordingly. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lack of leisure and recreational activities meant that service users social interests cultural and social needs were not fully met. Visiting from relatives and friends is flexible. Service user autonomy and choice was not maximised in relation to meals and mealtimes. EVIDENCE: Wherever practicable service users were able to make choices about aspects of their lives. The registered manager commented that service users could stay in their room and eat their meals in their rooms if they wanted. One service user was observed using his bedroom for most of the day and told the inspector, “I like my room it’s got it’s own toilet and that’s what I like about it. I can see people coming and going and I like to eat my meals at in here too”. Service user files and care plans held limited information about their interests and the information that was used was not part of an activity plan. This meant that there was not enough information to provide needs led life-enhancing activities for the service users. One service user who enjoyed monthly visits to Bury market said that he was very disappointed not to have done this since moving into the home more that a year ago. He said, “I haven’t left the home Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 13 since moving in, except for hospital appointments. I used to go to Bury and Todmorden market when I lived at Whinberry View Care Home. I just want to get out and buy my own things, once a month will do me. I can’t use public transport because I have severe back problems and the journey is too uncomfortable”. The registered manager said that transport issues had prevented this activity from taking place but she would try to ensure the service user could make monthly visit to the local markets. The registered manager was reminded that all service users must be given the choice of options available and she must make sure that activities are provided to meet their individual social needs. Regular attempts must be made to include the preferences of the majority of the service users. This must be agreed with service users and recorded in their care plans. The staff team were all white British but this reflected the current service user group. The registered manager said that service users religious and cultural needs are assessed and identified when they move into the home as part of the admission process. She said that she would use appropriate agencies to meet the diverse cultural or religious needs of other service users when required. Menus were changed regularly and service users were reminded of the day’s menu each morning although when asked what they were having for lunch that day six service users didn’t know that lunch was mince and onion, potatoes and peas. The inspector observed staff ready to offer assistance in eating to service users. One service user who needs liquidised food was presented with a bowl that contained something that had the texture and appearance of clay. When asked what it was the inspector was told this was the service users lunch of mince and onions, peas and potatoes and it had been liquidised together. The inspector advised in order to maintain service users appetite and nutrition food should be well presented and if liquidised should be attractive and appealing in terms of texture, flavour and appearance. The service user received another lunch that was presented properly. Discussion with a service user about meals highlighted problems with the meal times and when they are served. He said, “I would change the meal hours in this unit if I could. Breakfasts are always late due to the staff getting the others who live here up”. Another service user said, “When the cook was off we got too many burgers and sausages. Today the food was ok but it’s usually bland”. Another service user said, “Meals, not very satisfactory, things have gone down hill, burgers and sausage”. The registered manager was told what the service users said about the meals. She was also reminded that all cutlery and serving dishes must be returned to the kitchen to be sterilised after use to prevent cross infection. She said she had spoken to the cooks about mealtimes and was trying to arrange for these to be put back to 1pm to suit service users. Also she would discuss the variety and options of meals available to service users with the service users and cook and ensure kitchen utensils are cleaned following guidelines in the homes healthy and safety policy and procedure. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints made by service users were acted on and recorded. Staff were trained in the protection of vulnerable adults. EVIDENCE: There is a complaints procedure that is up to date, clearly written and can be made available in other formats. When asked if service users knew who to complain to they had a good understanding of how to make a complaint. One service user said, “I know who to tell and I do tell the manager. She sorts things out for me”. The homes complaints procedure specifies how complaints may be made and who will deal with them. There is an assurance that complaints will be responded to within a maximum of 28 days. Training of staff in the area of protection is regularly arranged and is ongoing at the home. There were procedures for staff to follow if they suspected an incident of abuse had taken place. 27 staff had received abuse training in this area knew what procedure to follow in the event of abusive practices. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-maintained environment that is kept clean and free from offensive odours. Patterned carpets provided on the dementia unit confused some of the service users. EVIDENCE: Case tracking and a tour of the building showed that the home is split into four separate living units each refurbished and redecorated to create an environment that is cosy and homely. A tour of the building confirmed that each of the four living units were pleasant and safe. However discussions with relatives and staff highlighted that the carpet in the dementia care unit is patterned and often confuses service users who can be seen frequently trying to pick out the pattern from the carpet. Another relative told the inspector, “The building structure and things like the carpet doesn’t help the staff do their job”. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 16 Many of the bedrooms were en suite and one service user said, “It’s much better for me having my own toilet I don’t have to bother going out there and waiting”. All units were well lit, clean, and tidy and smelled fresh. A ventilated conservatory on another unit provided service users with an indoor smoking area. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): OP 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment process ensured the protection of service users. Care staff were trained to carry out duties expected of them. Low staffing levels did not take into account the times of high and low activity and staff were not always available to immediately help service users. EVIDENCE: The duty rota was examined and showed which staff were on duty and at what times. Discussion with service users, relatives and staff highlighted that care staff were not on duty in sufficient numbers. One relative said, “There are not enough staff, I’ve seen staff run off their feet”. Another relative told the inspector, “These girls are fantastic, my mum’s well cared for but the girls are terribly stretched”. Discussion with a care assistant confirmed that care staff are over-stretched. She said, “The needs of the residents on this unit have changed, and their needs are more demanding. Out of 8 service users 7 need help getting up and help with washing and dressing and some need a hoist. Everybody has to be up, washed and dressed by the time breakfast comes at 9am however the residents don’t get their breakfast until about 9.20am are missing regular baths because there isn’t enough time with only 1 staff”. Care plans and records were checked and confirmed one service user who should have a weekly bath had not had one since 4th January 2007. The registered manager said this shouldn’t happen and would look into why this had happened. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 18 When asked about staffing levels and availability of staff one service user said, “There is not enough staff on here. I have to time when I want to go to the toilet to when I hear staff passing by. I give them a shout but sometimes they tell me to wait. This morning I wet myself because nobody had brought me a urine bottle and I had to use the bucket. You can put up with staff sickness or holidays for a week or two but not on a regular basis. The manager told me we wont get any more staff on this unit. The amount we pay a week, it’s ridiculous”. The manager confirmed that according to her line manager there would be no extra staff employed at the home. This meant that staff can not fully meet service user needs because there are some times when there are no staff there to immediately help them. The files of two new employees were examined and showed that the registered manager had followed the homes recruitment procedures. All pre employment checks had been carried out and there is accurate recording at all stages of the process. The service provides a comprehensive training programme including safe handling of medicines, dementia care, safeguarding adults and, moving and handling for all levels of staff. A record of training and development by all staff was examined. 96 of the care staff was qualified to NVQ Level 2 and above. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 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): OP 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of service users. The health, safety and welfare of service users and staff are promoted and respected. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. She demonstrates the ethos of leading by example providing hands on care to complement and increase the low staffing levels. She is aware of current developments receiving regular training to update her knowledge. Case tracking and examination of records confirmed the home has sound policies and procedures that are reviewed and updated regularly. There is a clear health and safety policy and records of equipment checks examined were up to date and accurate. Service users are provided with facilities to keep their valuables and money safe. There is a safe system with clear records that are Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 20 kept to track individual service user finances. Quality assurance systems are in place to ensure services are provided to meet service user needs. Service users are able to take responsibility for managing their own money and there is a safe system and records are well maintained. A record of water temperatures was kept along with other relevant health and safety records. All staff had received mandatory training in safe working practices including moving and handling, food hygiene and first aid. Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 22 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 (1)15(2) Requirement The registered manager must ensure that all service users are provided with a plan of care that sets out in detail the action to be taken by care staff so that all aspects of the health and social care needs are met. Service users or their representatives must be consulted as to how these needs are to be met. Care plans must be properly reviewed at least once a month. Timescale of 05/05/06 not met The registered manager must ensure that care staff maintain the personal and oral hygiene of each service user. The registered manager must ensure there are risk assessments for service users who self-administer medication. The registered manager must ensure that all medicines including Controlled Drugs in the custody of the home are handled according to the requirements of the Medicines Act 1968 and relevant guidelines from the DS0000036431.V302684.R01.S.doc Timescale for action 09/02/07 2 OP8 12(1) 09/02/07 3 OP9 13(4)(c) 09/02/07 4. OP9 13(2) 09/02/07 Olive House Version 5.2 Page 23 Royal Pharmaceutical Society. Timescale of 06/02/06 not met. Alcohol stored in the medicine cabinet must be removed. 5 OP10 12(4) The registered manager shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users by removing care task reminders from service user bedroom walls. The registered manager must ensure that details about service users current interests are included on the service user care plan and. Timescale of 05/05/06 not met The registered manager must ensure there are suitable arrangements in place to enable service users to engage in local social and community activities of their choice. The registered manager must ensure that wholesome and nutritious food is varied, available and suitably presented at such times when required by service users. The registered manager must ensure that a suitably qualified person with specialist knowledge of the service user group makes an assessment of the carpet on the dementia unit to demonstrate that the patterned carpet is not a helpful design feature to service users with dementia therefore inappropriate to the needs of the service users on the unit. The registered manager must ensure that staff ratios are determined according to the assessed needs of service users. Additional staff must be on duty DS0000036431.V302684.R01.S.doc 09/02/07 6. OP12 16(m)(n) 09/02/07 7 OP12 16(2) (m)(n) 09/02/07 8 OP15 16(2)(i) 09/02/07 9 OP22 16(1) 27/04/07 10. OP27 8(1) 09/02/07 Olive House Version 5.2 Page 24 at peak times of activity during the day to reflect service user need and the layout of the home. Timescale of 06/02/06 not met RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Olive House DS0000036431.V302684.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!