Inspection on 05/09/05 for Oriel Care Home Ltd

This inspection was carried out on 5th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oriel Care Home Ltd 04/09/07

Oriel Care Home Ltd 24/10/06

Oriel Care Home Ltd 21/01/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Oriel House 87 Hagley Road Oldswinford Stourbridge DY8 1QY Lead Inspector Chris Fuller Announced 5 September 2005 th 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. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Oriel House Address 87 Hagley Road, Oldswinford, Stourbridge, West Midlands, DY8 1QY 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) 01384 375867 01384 443597 Mr & Mrs Ephraims Mrs Elizabeth Jane Linford Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Oriel House is situated on the main Stourbridge to Oldswinford Road, a short distance from Stourbridge town centre, where there is a range of local facilities. The home comprises two properties, which are linked by an enclosed walkway. The larger of the properties was constructed as a private dwelling in the mid 19th century and conversion works have been carried out in a sensitive way, with care being taken to retain many of the original features. All areas are decorated and maintained to high standards, with a rolling programme of maintenance being evident. There are twenty-five single rooms, twenty-one having en-suite facilities. Two conservatories, in addition to the living room and two dining rooms, ensure that residents have a choice of seating areas and association. There is an attractive garden, which provides a pleasant view from the conservatory and a safe area in which residents may exercise. The owners are involved in all aspects of the management and day-to-day activity of the home, ensuring that high standards are maintained. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a proportional inspection based inspection against a selected number of the National Minimum Standards. Twenty of the forty-three standards have been defined as Core Standards and it is acceptable to assess only these twenty across the two annual inspections with discretion to assess others where there may be concerns about the performance of the home. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, a review progress on meeting National Minimum Standards from last years inspections and focusing on aspects of service provision that require further development, or pose the most significant risk to service users. Some standards have not been inspected on this occasion. The plan was to assess progress against previous requirements and it was pleasing to find that all of these had been met. The home has recently had new proprietors and a manager has recently been appointed who has worked at the home for the last 12 years. The manager is assisted by a deputy manager and together they form a good working partnership to provide management support and guidance to staff over the shifts. A number of service users were spoken to during the inspection and their comments were very pleasing and positive. Feedback questionnaires had been issued to residents and their relatives/ carers. The CSCI received 8 replies from service users and 7 from relatives. Residents commented on the change of ownership missing the relationship developed from the daily contact they had with the previous owner / manager. The change has been relatively seamless with established staff promoted to management and senior posts and the new provider ensuring the standards of good practice in the home are maintained. The feedback was generally very positive. Some comments from residents received by the inspector included ‘the food is very good’ and “I have nothing but praise for Oriel Care Home and all its staff who are wonderful, we all get the best care.” The inspector would like to thank the owner, management team, staff, residents and visitors of Oriel House for their assistance and hospitality during the inspection. What the service does well: The home is accessible, safe and well maintained. The home is decorated to a high standard with good quality furniture and furnishings. There is an attractive garden, which provides a pleasant view from the conservatory. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 6 Upon the day of inspection the home was very pleasant and provides good living space for a range of purposes. The home received a 4 for this standard. A tour of the home identified that it is clean and hygienic with no offensive odours. The home has very comprehensive ongoing assessments, which are completed every six months by the staff with the involvement of the service user. In practice this means the staff are responsive to the individual daily routines of residents and any significant changes are addressed appropriately. A range of leisure opportunities are provided through a displayed activities programme. Links with the community reflect residents own established contacts, their interests and preferences. The home has a six seater Mercedes Traveller vehicle with side opening doors and good head room available to transport small groups of residents on outings and to events. The cook provides a good range of varied appetizing dishes and provides a choice at each mealtime. In addition to breakfast, lunch and tea the home offers a light supper. The dining rooms are attractively arranged with tables nicely laid out providing a pleasant atmosphere and creating a social environment. Feedback from relatives/carers stated, “The home in my opinion is excellent.” What has improved since the last inspection? The new owners are experienced care providers and have maintained the good standard of service provided at Oriel House. Regular visits are made to the home at least three times a week providing an opportunity for residents and staff to get to know and speak to the owners. The registered manager, the care manager and the administrator form a strong management team that have an enthusiasm and commitment to maintaining and developing a high quality care provision. The policies and procedures identified in the previous inspection report have been revised and updated. Care plans have been revised to address all of the needs identified in the comprehensive assessments and also include the daily routines of residents. A day to day folder for each resident has been established as a working file; to ensure records are current and easily accessed by staff. The home takes pride in being able to offer holistic care to the residents with a focus on developing relationships with residents and providing very individual care. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 7 There has been on going decoration of the premises as needed. The soft furnishings in Hagley Road Lounge have been changed. 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. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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 Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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 There is admission procedure includes a proper assessment prior to people moving into the home and offers the opportunity for them to view the facilities available. This ensures an informed decision can be made that care needs will be met. EVIDENCE: A sample of residents files were seen and found to be in well organised and in good order. Records are comprehensive and include a photograph of each resident, the care plan, six monthly reviews, record of health professional visits, daily progress report, weight monitoring, GP visits and appointments, Falls and moving and handling risk assessments. The files hold initial social care and health assessments. The administrator holds financial records for residents including terms and conditions and contracts. These were not inspected on this occasion. Prospective residents frequently access the provision through respite visits initially that support them in the community; it also gives them an introductory visit to the home. There are rarely vacancies at the home. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 10 Each resident is given a welcome brochure which were seen by the inspector in individual rooms. This provides information about the home’s statement of purpose and other relevant details. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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 Care plans have been revised to provide comprehensive arrangements to meet all aspects of the individual needs identified in the assessment. There are clear health care plans with accessible tracking of appointments and treatments. These improvements ensure the health and welfare of the residents is being met. EVIDENCE: Care plan formats are produced on the computer and have been revised and expanded to address all aspects of residents needs. All care plans are reviewed monthly and a six monthly formal care review is held with relevant parties consulted. The staff are encouraged to develop relationships with residents and enable and encourage them to maintain their living and social and personal care skills. Feedback from residents indicated they thought the staff were “wonderful” “very thoughtful and helpful”; relatives/carers stated, “Staff are very caring.” The following risk assessments are completed and included in the care plan: falls, nutrition, continence. The District Nurse is requested to make an assessment of tissue viability if necessary. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 12 A format has been produced for all healthcare appointments to be documented in a chronological order. Records are also kept of the GP contacts, visits and appointments. A written procedure has been produced to be completed by staff undertaking blood sugar monitoring which is agreed by diabetic nurse practitioner. The practice nurse also gave training in respect of weight, special diets and food supplements. Five residents self-administer medication including creams and lotions. These are all recorded on MAR sheets and signed for. Prescriptions are kept of medication to ensure MAR sheets are accurate. The self-medication policy has been amended to identify how staff will check compliance. The registered manager confirmed the home has written confirmation from the local pharmacist regarding secondary dispensing as well as dispensing in advance of administration. The medication policy and procedure has been expanded to include receipt, returns and disposal of medication. During observation of the administration of medication it was noted that the relevant coding was not being used as listed on the MAR sheets. This can potentially lead to misinterpretation and is not helpful if tracking the reasons for none administration of medication. The registered manager stated that all staff administering medication have complete medicine management training in the safe handling and administration of medication through a distance learning programme. In order to meet the national minimum standards an accredited training programme must be completed. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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 The management and staff are committed to support of lifelong learning and development for each resident. This is demonstrated through the ethos of the home and in the programme of activities offered. It provides a selection of menus with choices at each meal. Every effort is made to reflect the individual wishes and preferences of residents. EVIDENCE: The residents spoke of a recent birthday celebration for one resident who was one hundred years of age. Staff make an effort to celebrate seasonal events and special occasions. Residents meetings are held regularly to seek their views about the daily routines and service provision in the home. Feedback from relatives/carers stated, “There are always Social events during the week to keep everybody alert”. The activities on offer include quiz, musical exercises, flower arranging, crafts and news of the world. Residents also maintain their links and contacts in the local community attending a range of clubs such as Age Concern day centre, skills club for the blind, MS club, Bridge Club and local churches. Visiting ministers also call at the home and the church service will be watched on TV. There are local entertainers booked for social and leisure time. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 14 The inspector took lunch with the residents in a dining room that had tables pleasantly laid up. There is limited space in the dining room and residents and staff worked well together to enable people to be seated comfortably. Meal time was a social occasion and residents enjoy each others company and conversation. The registered manager provided revised copies of two weeks menus for the home; including supper. There is a good choice of dishes available at each mealtime to reflect people’s preferences. The food was attractively presented and dishes are generally home cooked, wholesome and nutritious. In addition drinks and snacks are available upon request. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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 and 17 There is a complaints policy and procedure accessible to residents and visitors to the home. The management and staff are proactive in addressing issues as they arise and take concerns and issues raised seriously; resolving matters where ever possible to ensure the safety and well being of the residents. EVIDENCE: The registered manager reported in the pre-inspection information that there had been no formal complaints received during the past inspection year. The complaints book seen held no record of complaints. The complaints policy and procedure had last been revised on 10/02/05. The information regarding making a complaint is made available to residents and relatives through packs in each room and is displayed on the notice board. Each resident has a key worker who is a senior care staff. They regularly complete monthly reviews with the resident; this and the six monthly review provide one to one formal opportunities for residents to raise issues and for staff to check out any changes or concerns. Similarly communal living issues can be aired and addressed through the six monthly residents meetings of which minutes are kept. In addition to this, annual questionnaires are sent out by the management as part of the quality assurance process and responses are collated and acted upon. The management do provide information about advocacy services to the residents. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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) 19,20,22,24,25 and 26 The home is conveniently situated close to local amenities and public transport. The homely environment is well cared for and utilised to its full potential and for the benefit of the residents. The management team were aware of issues brought to their attention and in the process of addressing them. There is an ongoing programme of maintenance, repair and decoration in consultation with residents to ensue a pleasant and homely environment. EVIDENCE: The home is well maintained and decorated to a high standard with good quality furniture and furnishings. There are twenty-five single rooms, twentyone having en-suite facilities. Two conservatories, in addition to the living room and two dining rooms, ensure that residents have a choice of seating areas. There is an attractive garden, which provides a pleasant view from the conservatory. The home was quite busy on the day of inspection showing good use of the communal and private space with a range of activities in different areas of the house such as hairdressing, exercises and in the afternoon a discussion of current affairs. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 17 A tour of the premises was made by the inspector including several of the individual rooms. One of the individual rooms seen had a carpet that was ridged due to stretching from general wear and tear. This presents a health hazard due to the resident as a potential trip factor. The registered manager agreed this would receive attention to make it safe. In the communal areas visited the lounge door had significant gaps and it was agreed this would be addressed to meet health and safety standards. One of the issues discussed with the registered manager was the access to the building for those with limited mobility and wheelchair users. Feedback from residents had indicated “A ramp into the house” would enhance their independence. The registered manager confirmed this was under review for future planning and development. The infection control policy has been expanded to include a procedure to follow in the event of an outbreak of diarrhoea and vomiting. There have been no reportable incidents during the past inspection year. Staff are due to receive training in this safe working practice topic. At the time of inspection the home was clean and hygienic with no offensive odours. The home has a small laundry area with 2 industrial washing machines and 1 tumble drier. At the present time all staff assist with the laundry and cleaning duties. Response to questionnaires from relatives/carers stated, “Oriel House is always very clean, and comfortable. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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) 27,28,29 and 30 The management team have made good progress in implementing staff policy and procedures; recruiting and retaining a competent staff group. Staff are given support and encouragement through training and supervision. The organisational structure for staff duties and responsibilities needs to be reviewed to ensure an appropriate mix of staff are appointed to meet the needs of the residents, the layout and purpose of the home, at all times and fulfil the national minimum standards. EVIDENCE: The home does appear to provide a sufficient number of care staff to meet the needs of the residents. Certainly the feedback received and the inspector’s observations of care practice at the home indicates that the care needs of residents are being met. At the present time there are three staff on duty to provide care for twenty five residents, mornings, afternoon’s and evenings. An additional three care staff are provided in the morning; two to cover breakfasts and one takes a lead on cleaning. There are two care staff on duty over night. The home procedures include a handover at the beginning of each shift with a folder holding a written record of details of duties to be completed. Statutory requirements have been made regarding staffing due to the fact that care staff duties include cleaning and cooking. For health and safety reasons it is not appropriate that staff move between these three areas of duties due to the potential for cross infection. The national minimum standards clearly state that domestic staff should be employed to cover kitchen and cleaning duties. Also there are staff and deployment issues relating to day and night care Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 19 provision given the layout of the premises and how staff assist each other These issues were discussed with the registered manager at the time of the inspection. The organisational structure for staff duties and responsibilities needs to be reviewed, to ensure staff are informed and skilled in their specific duties and responsibilities, to meet the needs of the residents and fulfil the national minimum standards. The home employs 32 care staff and 4 ancillary staff. Good progress has been made with the attainment of qualifications. There are currently 18 staff with level 2 or above. The home has received a 4 score rating as it exceeds the standard providing 57 of qualified staff by 2005. Eighteen of the staff also hold a first aid certificate. Sixteen of the staff are responsible for the administration of medication. The manager has reviewed the recruitment and selection procedure/practice to ensure that all references received are authenticated and gaps in employment history are explored. A sample of staff files were seen and were found to be well organised and in good order. Previous employment records did not hold a copy of the interview questions and outcomes. The management team are developing the interviewing process and agreed to produce set questions for interviews and a system of selection. Records will be held on file. The management provided information of the training programme for staff in the pre inspection questionnaire. Training has mainly been in the safe working practice topics including emergency first aid, moving and handling, food hygiene, fire training and infection control. Some of the courses planned are as follows: continence awareness, wastes management and medicine management. Staff confirmed they feel encouraged and supported through training and guidance from management. NB. The provider also has a sheltered housing provision on the same site Beech House complex for four people. They share some of the same facilities with meals being provided and access to the activities. One carer is employed solely to support the residents of Beech House. This care staff is not included in the above numbers. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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) 31,33,37 and 38 The home has been through a period of change with new ownership and new management. It is to the credit of new owners, the management team and the staff that the high standards and personable ethos of the home have been maintained and continue to develop and be responsive, to meet the needs of the residents. EVIDENCE: Jane Linford is the new registered manager with a vast experience of care provision. Mrs Linford has worked at Oriel House for 10 years and has completed her NVQ 4 and Registered Managers Award. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 21 The home uses the Mulberry House quality assurance tool, which informs the home’s annual development plan. The home annually consults residents and their families about the service provided and collate responses received. The pre inspection questionnaire indicates that policy and procedures are regularly reviewed and updated. The management team and staff have been timely and efficient in taking action to address issues and statutory requirements raised in the CSCI inspection reports. The new owner stated that Regulation 26 visits and reports are not made as regular visits are made to the home at least three times a week when the operation and systems of the home are monitored. On arrival at the home the Inspector was able to access the building uninterrupted and there was no signing in process for visitors. The registered manager explained that residents and relatives enjoyed the freedom of access to the home. It is important for the safety and security of all those living and working at the home that this practice is reviewed in consultation with residents and their relatives. There is a programme for staff to complete training in all safe working practice topics. The registered manager confirmed that staff receive a minimum of 2 fire lectures a year. Records are kept of staff attending the fire training. The most recent training session was held on 2.09.05 with 8 staff in attendance. Infection control training has been planned for October 2005 for the staff group. Pre inspection information notes that management have been effective in ensuring that all the relevant maintenance and associated records have been completed during the past twelvemonths. The registered manager confirmed that recommendations and identified works have been completed. Staff spoken with throughout the inspection confirmed and demonstrated that equipment used in the home was in working order. The inspector notes the five year electrical wiring certificate was last completed in 12.09.01. Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 x 2 x 2 3 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 x 3 x x x 2 3 Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 23 NO 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 9.3 Regulation 17(1)(a) Requirement The registered manager must ensure the relevant coding is used as listed on the MAR sheets. The registered person must ensure that all staff administering medication complete accredited training in the safe handling and administration of medication. Replace the lounge door to meet fire safety standards. Review access arrangements to the premises for those with restricted mobility and wheelchair users; Provide a ramp. Replace or make safe the carpet in Room 9 The registered person and registered manager must ensure the staffing numbers and skill mix of qualified / unqualified staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home, at all times. The registered person and registered manager must ensure domestic staff are employed in Timescale for action 20/09/05 2. 9.7 13(2) 31/12/05 3. 4. 19.5 22.2 23(4) 16(1),(2)( c) 31/12/05 31/03/06 5. 6. 24.4 27.1 16(1),(2)( c) 18(1) 06/10/05 31/12/05 7. 27.7 18(1) 31/12/05 Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 24 8. 29.1 19(1) 9. 10. 11. 37.1 38.2 17(1) 13(5),23( 4) sufficient numbers to ensure that standards relating to food are fully met, and the home is maintained in a clean and hygienic state. The registered manager must 31/10/05 ensure a thorough recruitment procedure based on equal opportunities through maintenance of interview records and decision making. The registered manager must 20/09/05 ensure records are kept of all visitors to home. Ensure all staff are trained in 31/10/05 safe working practice topics including Infection Control. 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 Good Practice Recommendations Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 Page 25 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8BR 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 Oriel House E55 S63620 Oriel House V239153 050905 Stg4.doc Version 1.40 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!