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Inspection on 14/04/05 for Orsett House Retirement Home

Also see our care home review for Orsett House Retirement Home for more information

This inspection was carried out on 14th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager assesses potential residents and this information is transferred into the care plans. A new assessment tool will further improve this process. Privacy and dignity is upheld in the Home and this was confirmed by the residents, staff and a visitor. The residents are encouraged to make as many choices as they are able in their daily lives. A menu is available every day and those residents asked said that the food provided was very good. Each resident has their own bedroom and these are pleasantly decorated and equipped with good quality furnishings and fittings. Residents are encouraged to bring some of their personal possessions into the Home with them. The residents spoke highly of the care staff team and respectful attitudes were observed, whilst both enjoying a healthy banter. The care team and residents speak highly of the management team and their support and dedication.

What has improved since the last inspection?

There have been vast improvements since the last inspection and twelve of the sixteen requirements made in November 2004 have now been met. The care plan information is far more detailed and now covers all areas of individual need including health care monitoring. Care plans are reviewed monthly. There is evidence available that medical assistance is accessed, as required. The medication procedures have been improved since the last inspection and staff are being trained thoroughly to administer drugs.A weekly activities programme has been initiated and records are kept of the results. Outside entertainers visit the Home regularly and a keyboard player/singer entertained some of the residents on the afternoon of the inspection. Some work has started to implement a formal staff supervision system and to evaluate staff training. Seated weighing scales have been purchased for the Home and a all bed guards now have protective coverings. A new assisted bath is being planned. Residents’ meetings are now being held.

What the care home could do better:

Concerns have been raised about the safety of an upstairs fire door and the security arrangements at the front door. The advice of the fire safety department must be sought. Staff files were not available at this inspection and therefore it was not possible to check whether the previous requirement regarding Criminal Records’ Bureau checks. The Home must ensure that the staff files contain all of the required information and this is listed in Schedule 2 of The Care Homes Regulations. Further work is required to assess staff training and ensure that the required training is being delivered as often as it should be.

CARE HOMES FOR OLDER PEOPLE Orsett House Station Road Barlaston Stoke on Trent ST12 9DQ Lead Inspector Sue Jordan Unannounced 14 April 2005 12:30 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. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Orsett House Address Station Road Barlaston Stoke on Trent Staffordshire ST12 9DQ 01782 372147 01782 374336 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) Mr Frederick Cozier Mrs Coral Cozier Mrs Mavis Toft Care Home 49 Category(ies) of OP - 49 registration, with number DE(E) - 34 of places PD(E) - 15 Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/11/04 Brief Description of the Service: Orsett House is a care home that can accommodate up to 49 older people of both sexes. Within that number, 32 may have a primary diagnosis of dementia and 17 may be physically disabled. There were 47 people resident at the home at the time of this inspection.Orsett House is a large Victorian type residence that has been sympathetically extended by the current owners to provide a high degree of purpose built accommodation. The home is divided into two separate units to meet the needs of the different service user groups. In each unit, accommodation is provided to both floors and access is by stairs or passenger lift. Each unit enjoys its own communal areas, dining area, assisted bathing and toilet facilities. There is a central laundry and kitchen but there is a small satellite kitchen on each unit for the preparation of hot drinks.The home is situated in the centre of Barlaston village and is close to all local amenities such as the railway station, local shops, public houses, education and recreational centres and the parish church. There is a bus service and the village is dissected by the Trent and Mersey canal that is close to the location of the home. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and quarter hours. A partial tour of the Home was undertaken, twelve residents and four staff and the manager were spoken to and the case tracking of three care plans. Some staff records were examined and observation of a planned activity took place. What the service does well: What has improved since the last inspection? There have been vast improvements since the last inspection and twelve of the sixteen requirements made in November 2004 have now been met. The care plan information is far more detailed and now covers all areas of individual need including health care monitoring. Care plans are reviewed monthly. There is evidence available that medical assistance is accessed, as required. The medication procedures have been improved since the last inspection and staff are being trained thoroughly to administer drugs. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 6 A weekly activities programme has been initiated and records are kept of the results. Outside entertainers visit the Home regularly and a keyboard player/singer entertained some of the residents on the afternoon of the inspection. Some work has started to implement a formal staff supervision system and to evaluate staff training. Seated weighing scales have been purchased for the Home and a all bed guards now have protective coverings. A new assisted bath is being planned. Residents’ meetings are now being held. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 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 standard(s) 3, 5 Assessments of potential service users are undertaken in their current setting and these are to be further improved by the introduction of new, more comprehensive formats. EVIDENCE: The manager visits potential service users in their current setting and undertakes an assessment. This was confirmed in discussions with the assistant manager and by a newly admitted resident. The information gathered at assessment is transferred into the care plans. A new format is to be introduced, which will enable an even more comprehensive assessment of need. A visitor spoken to confirmed that the family had visited the Home before making a decision as to whether their mother should live there. He also said that he thought his family had received some form of information pack. A recently admitted resident explained that a meeting was to take place the following day with her family and social worker. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 9 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, 10 There have been major improvements in care planning and health care monitoring. The Home is now using the care plan documentation to its fullest potential. EVIDENCE: Of the twelve residents spoken to at this inspection, three of their care plans were chosen to inspect. These confirmed the information and wishes expressed by the residents. The care staff spoken to were aware of the residents’ needs, although they admitted that they rarely looked at the care plans and that they are usually informed of any changes to the care plans at handover. However, staff reported that the manager has informed them of the accessibility of the written care plans and the importance of reading them regularly. A visitor spoken to during this inspection was not aware of his mother’s care plan, although stressed that other family members may be. He expressed his satisfaction with the care delivered to his mother. The formats used by the Home are now being completed to their full potential and this has been remarked on by the organisation responsible for developing them. Each of the care plans examined had been reviewed monthly and additional detail added, if necessary. A concern and subsequent requirement was made at the last inspection that more detail is required in the personal risk assessments. A Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 10 new format has been obtained by the Home, which will allow for more recorded information and this will be checked at the next visit. The health care sections of the care plans evidence that needs are closely monitored and medical professionals contacted, if necessary. The proprietor has recently purchased seated weighing scales, which means that all of the residents can now be weighed regularly. Evidence of monthly weight monitoring is in the care plans. Two of the residents spoken to require fluid and nutrition intake monitoring and these are now recorded more diligently. The Home has ceased the practice of self-recording medication on the medication administration sheets and they are now receiving pre-printed sheets from the pharmacist. A senior care worker and care worker were spoken to during this inspection and they have both undertaken distance learning medication training, based on a module system. The pharmacist has audited the medication systems and in addition comes into the Home monthly. A thermometer has been placed in the medication storage area. A recently admitted resident self-administers her medication and lockable storage space is available in her bedroom. A risk assessment is required to support her independence. One of the residents explained that she regularly uses the phone to speak to her family. Another has her own phone and phone line in her room. A member of the care staff reported that residents are allocated particular days for bathing, but that they can also be bathed in between times. She also spoke of the importance of high standard personal hygiene and clothing; that “residents should feel and look good”. One of the residents said that her laundry is returned to her well cared for. A partial tour of the environment was undertaken with a member of the care staff team and she was observed knocking on bedroom and bathroom doors, prior to entering and asking permission of the residents before introducing the inspector. The son of one of the residents was spoken to during this inspection and he confirmed that he and his family are made welcome in the Home. During this visit, he was supported by the staff to take his mother into the summer house. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 11 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, 15 More emphasis has been placed on structured activity planning and the recording of this. It is hoped that future training in dementia care needs will assist in providing worthwhile activities and stimulation for these residents. Visitors are made welcome in the Home and various avenues for encouraging resident choice are in place. EVIDENCE: A weekly activities plan has been developed and records are now kept, as evidence, of attendees and the outcome of the sessions. The manager explained that two staff members are particularly enthusiastic about activities and that she is hoping to utilise this. The residents of the annex area of the Home were asked whether they wished to join in a music session, provided by an external entertainer in the main Home. Most refused and two ladies said that they were “rather set in their ways”. To combat this, the venue of the activities swaps between the Home and the annex. One of the residents had a large print book, which she believed came from the visiting library van. The proprietor has send off for a dementia care training pack. As a result of this training, the manager should explore further activity and stimulation for those residents with more severe dementia care needs. One of the residents explained that he walks daily to the local shop for a newspaper. Another said that she got involved in all organised activities. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 12 Family of two of the residents were seen visiting during this inspection and one was spoken to. He confirmed that he and his family are made to feel welcome in the Home and between them visit regularly at various times of the day. He also thought that the family had received written information about the Home prior to the admission of his mother. He was enabled by staff to take his mother into the summer house, so that they could enjoy some privacy. Residents’ meetings have been introduced and a notice was seen in the annex area of the Home. One of the residents confirmed his knowledge of the meeting and the issue he wished to discuss. Residents were asked if they were able to choose when to go to bed and rise in the morning, all of those spoken to, confirmed that they were. A care worker was asked how the Home encourages choice for the residents and her answers included the residents’ meetings, involvement in menu planning and knowing the residents’ likes and dislikes. She also stated that she had worked all of the shifts in the Home and that the residents are able to choose when to go to bed and rise in the morning. She said that residents wandering or unsettled at night would be offered a drink and some sit with the night staff and watch television until they feel able to return to bed. A large notice board informs those residents able to read and understand of the day’s menu, the weather, the staff on duty and the activity arranged. A visitor explained that his mother had brought many of her personal possessions with her into the Home and a staff member confirmed this as usual practice. This inspection started at lunchtime and a number of residents were asked if they had enjoyed their meal, all said that they had. Two residents spoken to said they weren’t offered a choice at lunchtime, but that generally they enjoyed the food. The menu board showed a choice of deserts and sandwiches at teatime. Two residents explained that drinks were offered at set times but that they thought they would be given a drink in between if they asked. A discussion was held with the manager as to whether a jug of juice could be made available, particularly in the annex area. Two of the staff confirmed that they had undertaken food and hygiene training, although it was not ascertained as to whether this is current. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 13 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, 18 Further evidence is required that all measures are in place to protect residents from abuse, including robust recruitment, staff training and knowledge of the appropriate procedures to follow. EVIDENCE: The manager did not know whether a hard-back book has been introduced for the recording of complaints. Some of the twelve residents spoken to at this inspection were asked if they knew with whom to address concerns or complaints. All said that they would speak to the manager and that she is very approachable. Some also said that they felt able to speak to staff members. A visitor spoken to during this inspection was unable to confirm that he or his family had received a copy of the Home’s complaints procedure. However, he did say that other members of his family may have. He did state that the manager had asked the family to address any concerns with her and that he would feel comfortable enough to do so. The manager was unable to access staff files and therefore it could not be ascertained as to whether CRB disclosures are now in place and recruitment procedures strengthened since the last inspection. Staff training is presently being evaluated and deficiencies identified. It was confirmed that this is work in progress and as yet incomplete. Therefore it was not possible to ascertain as to whether all staff have received training in Adult Protection Procedures. Three care staff spoken to during this inspection did not report having received this training. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 14 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, 24,26 The Home is well maintained and provides a comfortable environment for its residents, although advice is required from the fire safety officer regarding a fire door and the front door security arrangements. EVIDENCE: A partial tour of the environment was undertaken during this inspection of all of the communal areas, the bedrooms in the annex area and a fire door upstairs in the main house. A notification was received by the Commission for Social Care Inspection regarding an accident in which a resident with dementia care needs went through an upstairs fire door and fell down a stairway. This area was inspected and is considered to be a potential hazard to other service users, a concern also confirmed by the manager. A risk assessment of this area is required, which it is felt will confirm that safety arrangements must be put into place. The possibility of a buzzer system and protocol for its use was discussed, however this must be discussed with the Fire Safety Officer. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 15 Security of the residents is an issue within the Home, as many of the residents have dementia care needs and in their confusion have been known to wander. As a result the Home have introduced a security system onto the front door. As previously required, the manager must contact the fire safety officer and clarify that the present arrangements comply with fire regulations. All of the bed guards now have bumpers, as previously required and a new risk assessment format will mean that a more comprehensive procedure can be introduced for monitoring the safety of the bed guards. A poster containing information about the risks involved with bed guards is in the manager’s office. The proprietor has purchased new seated weighing scales and the rails round the toilets have been secured to the floor. There are plans to refurbish one of the bathrooms and provide a new assisted bath. All of the service users have their own bedroom and all of those seen were pleasantly decorated and contain good quality furniture and fittings. It was confirmed through observation and during discussions with a visitor and staff that residents are able to personalise their rooms, with possessions and some furniture from their previous homes. The infection control issues identified at the last inspection have been addressed satisfactorily, although during this inspection it was noticed that one of the bedrooms had a pungent smell caused by incontinence difficulties. The manager confirmed this as a problem and solutions to combat this were discussed. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The Home has a consistent and in the main long established staff and management team, however training and recruitment requirements do not fully allow for protection of the service users. EVIDENCE: A member of staff when asked said that staffing ratios are sufficient to the numbers and needs of the residents. A visitor said that he thought that there always appeared to be enough staff on duty and that he had visited at various times of the day. Domestic staff work in the mornings and two staff were seen working in the kitchen. The manager is supplementary to the care staff rota and works opposite her two assistant managers, ensuring good management cover. Three of the staff on duty were spoken to during this inspection and observations were also made of staff attitudes and respect towards the residents. This was very positive. Many of the residents spoken to praised the staff and this was also confirmed by a visitor. The Home has a consistent and mostly long established staff team. It was not possible to inspect the staff recruitment files as the proprietor was not available and therefore the concerns and requirements made at the last inspection are carried over and will need to be addressed at a future visit. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 17 Work has begun to analyse staff training and check that all staff are receiving mandatory training at the required frequencies. It was confirmed however that this is an on-going process and as yet not complete. Therefore it was agreed that this requirement would also be carried over into this report Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 18 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) 32, 33, 36, 38 The Home is managed by an experienced and consistent management team and they have addressed many of the concerns expressed at the last inspection with commitment and enthusiasm. EVIDENCE: Staff, residents and a visitor told of the manager’s approachability and support. The home is owned and overseen by its proprietor and a member of staff stated that he is “the best boss she’s ever had” and equally approachable. The manager works opposite her two assistant managers and as such the Home has constant management support. Quality questionnaires have recently been sent to the residents’ families. Evaluation of the results will need to be added into the Service Users’ Guide. Residents’ meetings have recently been introduced. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 19 The manager has recently implemented a formal staff supervision system and her records indicate that most of the staff team have attended one supervision session. The system involves a supervision contract between the manager and supervisee and written records will be signed by both parties. Although, all staff spoken to during this inspection confirmed that they are well supported by the management team, none confirmed that they had attended an individual supervision session. All reported attending regular team meetings and handovers are held at the end/beginning of each shift. The manager reported that a Health and Safety was undertaken in January 2005 and a report produced, although this was not seen during this inspection due to the absence of the proprietor. Fire safety concerns have been highlighted earlier in this report and subsequent requirements made. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x 3 3 3 x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x x 3 x 2 Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 21 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 18 Regulation 13 (6) Requirement Timescale for action 01/07/05 2. 19 3. 19 4. 5. 6. 26 9 29 Further evidence is required that all measures are in place to protect residents from abuse, including robust recruitment, staff training and knowledge of the appropriate Adult Protection Procedures to follow. 23 (4) The Home must ensure that the present security arrangements used at the front door comply with fire safety legislation and guidance. The manager must contact the fire department. Previous Requirement 23 (4) A risk assessment of the upstairs fire door must be undertaken and following the advice of the Fire Authorities, safety measures be put into place. 16 (2k) Measures must be taken to conteract offensive odours in the Home. 13 (2) A supporting risk assessment must be undertaken for selfadministration of medication. 19, The manager/proprietor is 18,Schedu required to ensure that staff files le 2 contain all of the elements listed in Schedule 2 of The Care Homes Regulations. Current legislation demands that staff can only E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc 01/05/05 01/05/05 01/06/05 & on-going 01/05/05 01/05/05 Orsett House Version 1.20 Page 22 7. 30 18 (2) 8. 38 12, 13, 23, 17 commence employment following a successful POVA 1st check and submission of a CRB application. Previous Requirement Training needs to be reviewed to 01/06/05 ensure that all staff be appropriately equipped to perform their roles and meet the needs of the service users. Previous Requirement The registered manager must 01/05/05 & ensure so far as is reasonably on-going practicable the health, safety and welfare of service users and staff. This relates in particular to the fire safety requirements made. Previous Requirement 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 16 Good Practice Recommendations It is recommended that the home obtain a hard back book to record contemporaneously the date that a complaint is received, the name and contact details of the complainant if known, the nature of the complaint, the action taken to address the complaint and the final outcome. Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Orsett House E51-E09 S4988 Orsett House V22135 140405 Stage 4.doc Version 1.20 Page 24 - 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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