Inspection on 09/11/06 for Park Manor

This inspection was carried out on 9th November 2006.

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

The inspector 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

Park Manor 20/07/07

Park Manor 23/02/06

Park Manor 31/05/05

Park Manor 23/11/04

Park Manor 27/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Park Manor 8 St Aldhelms Road Branksome Park Poole Dorset BH13 6BS Lead Inspector Amanda Porter Key Unannounced Inspection 10:35 9 & 14th November 2006 th 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 DS0000004055.V317116.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. DS0000004055.V317116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Manor Address 8 St Aldhelms Road Branksome Park Poole Dorset BH13 6BS 01202 764071 01202 765505 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) Park Manor Limited Mrs Janice Scanlon Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places DS0000004055.V317116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Park Manor is situated in a residential area of Branksome Park. The local area has a range of shops, a post office, library, public house and other leisure facilities. Public transport is accessible with bus routes and a train station nearby. Park Manor is a large house built in the late nineteenth century. Many of the original features are incorporated into the current building, which has been extended and adapted to accommodate older people. The home has substantial grounds, surrounded by mature trees and shrubs. The gardens are kept to a high standard. Accommodation at Park Manor consists of single and double rooms for service users, all with en-suite facilities; a passenger lift provides access to the first and second floor. Spacious communal areas are available to service users and include two sitting rooms, a large dining room and a smaller dining area. A large Victorian conservatory overlooks the well-maintained gardens. There is also a small interview room which is available to service users should they wish to receive visitors in private in an area other than their bedroom. The back of the house has been extended to provide 12 self contained apartments, each with its own front door and which include a sitting room, bedroom, bathroom with toilet and a small kitchen area. A lift operates on all 3 floors of the apartment block. The care, catering and laundry services of the main house also service the apartment block. At the time of inspection weekly fees ranged from £462 to £1000. Additional charges are made for hairdressing, chiropody, newspapers, toiletries, transport and telephone. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_peop le_choos.aspx DS0000004055.V317116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the two days of the 9th and 14th November 2006 and took approximately six hours. The purpose of the inspection was to review the requirements and recommendation made in the last report and to assess all of the key standards. The Registered Manager, Mrs Scanlon, and her staff were on hand to aid the inspection process. Information gathered for this report came from several sources including: • Reports made to the Commission for Social Care Inspection by the home. • A pre-inspection questionnaire completed by the registered manager. • 18 comment cards completed by residents; 12 by relatives/visitors and 4 by health and social care professionals. • Tour of the premises. • Review of a variety of documentation including care records, staff records, maintenance records, policies and procedures. • Discussion with residents and staff. Four residents and four members of staff were spoken with and asked their views on the service provided at Park Manor. Comments received in comment cards and through discussion included: “Residents always appear well cared for and their requests are met where possible. Carers appear to look after residents at a high level.” “Kindness of the staff is very evident.” “I am very pleased with the level of care at Park Manor. All the staff really look after my friend, the consequence of this I do not have to worry. All friends and relatives are welcome at any time day or night.” “I am happy in Park Manor, and everything possible is done to make me happy. The staff are good and hardworking.” What the service does well: Residents say that staff are very kind and considerate and their privacy and dignity is respected at all times. Residents’ health needs are well met by the home and community health professionals. Medication is well handled at the home to promote the health and well being of residents. DS0000004055.V317116.R01.S.doc Version 5.2 Page 6 Residents are encouraged to maintain their links with family and friends and visitors to Park Manor are made welcome. The home offers a good variety of home cooked food, which is enjoyed by residents. Meals can be taken wherever the resident chooses. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the needs of the residents. The Registered Manager confirmed that 60 of care staff held the level 2 NVQ Award (or equivalent), which meant that residents were in safe hands when these staff are on duty. Financial procedures within the home also ensure that residents’ interests are protected. What has improved since the last inspection? What they could do better: As a result of this inspection a total of eleven requirements and two recommendations have been made. The Registered Manager must ensure she undertakes a thorough assessment of any prospective service user’s needs, which include psychological and social needs, so that she can give assurance that those needs can be met by the staff at Park Manor. The absence of a clear, thorough and consistent assessment and care planning system to adequately provide staff with the information they need to satisfactorily meet residents’ personal, social and health care needs has the potential to place residents at risk. Social activities must be provided to satisfy the residents’ expectations and preferences. The registered person must ensure that the complaints procedure makes clear to the reader who will be investigating any complaint made. Arrangements for protecting residents from abuse are not satisfactory placing them at possible risk of harm. Park Manor’s policy for the protection of DS0000004055.V317116.R01.S.doc Version 5.2 Page 7 vulnerable adults needs to be reviewed so that it is in line with the Department of Health guidance “No Secrets”. The home has recently been rewired and therefore areas need to be redecorated. Most areas in the home were seen to be clean and free from any unpleasant odours. However the room used for storing medication and some areas in the kitchen were not clean, which could present a risk of cross infection. The home’s recruitment policy and practices do not ensure that residents are supported and protected. There is a high staff turn over at Park Manor. The home needs to continue to develop a training programme to ensure that all staff receive mandatory training in a timely fashion. This will equip staff with the ability to meet the assessed needs of the residents effectively at all times. To ensure that staff are made aware of management decisions in the home the minutes of staff meetings should be recorded and made available to all members of staff. To ensure that the home is well run in the best interests of the residents it must ensure the appropriate management systems are in place. This should include an annual development plan as part of the quality assurance monitoring system. To adhere to health and safety legislation the home must give manual handling training to all staff. Cleaning materials must be stored securely. 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. The summary of this inspection report can be made available in other formats on request. DS0000004055.V317116.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 DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process, prior to admission, is insufficient and does not enable the home to thoroughly assess a persons needs or establish whether those needs can be met. EVIDENCE: The pre-admission assessments for three residents were reviewed. It was evident that the resident and/or a member of their family was involved in this assessment on each occasion. However, the assessments seen did not contain enough information in all aspects of care on which to base a care plan. All the assessments were based on physical needs and did not include psychological or social needs. None of them contained sufficient information on social interests, hobbies, religious and cultural needs, which meant some needs the resident had may not be addressed on admission to the home. DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The absence of a clear, consistent and thorough assessment and care planning system to adequately provide staff with the information they need to satisfactorily meet residents’ personal, social and health care needs has the potential to place residents at risk. The health needs of the residents are met with evidence of good support from community health professionals. The medication at this home is well managed promoting the good health and well being of residents. Residents are treated with respect and their right to privacy upheld. DS0000004055.V317116.R01.S.doc Version 5.2 Page 11 EVIDENCE: The care documentation for three residents was reviewed. Each file contained a variety of risk assessments and care plans. Risk assessments were not based on any recognised assessment tool and a conclusion as to whether the risk was high, medium or low was reached as a matter of opinion and was open to interpretation depending on which member of staff undertook the assessment. Each resident had a plan of care, which mainly explained how physical needs were to be met but not psychological or social needs. Information on some aspects of physical care needs that had been highlighted in assessment was not then used in some care plans. One file seen for a resident due to leave Park Manor did not contain any care plan around discharge. There were no policies or procedures in place for staff to follow to ensure that a resident leaving the home was fully supported during this time. The Registered Manager confirmed that care staff rarely consulted the care documentation and were reliant on a verbal handover between shifts, which meant that some aspects of care could be overlooked. There was evidence in the files seen that the resident and/or a family member had been involved in drawing up the plan of care. Residents confirmed they had access medical services. Records were kept of visits from GPs, district nurses, chiropodist and opticians. The home has an informative medicines policy and procedure including reference to self-administration and associated risk assessment and arrangements for ordering, administration and disposal. Medicines were stored securely. Records were kept of the receipt, administration and disposal of medicines. Examination of records indicated that medicines are properly administered in accordance with the prescriber’s instructions. Comments received from residents and their relatives/visitors confirmed that staff treated them with respect and were supportive and kind. 17 residents responded to the question “Do you receive the care and support you need?” and 10 said “Always” and 7 said “Usually”. Out of the 18 responses to the question “Do the staff listen and act on what you say?” 15 said “Yes”; 2 said “No” and one said that it depended on which staff were on duty. DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The social and recreational needs of the residents are not wholly satisfied, which results in some residents being bored and under stimulated. The residents are supported in maintaining contact with their friends, family and the narrow community and in making decisions about their lives in the home. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: There were very few activities organised by the home and for those residents who did not wish to take part in the organised activities no plan was evident for how their social needs were to be met. Generally care documentation did not contain any assessment of social needs or information on how individual social needs were to be met. Some residents said they were bored but others were happy to organise their own activities. DS0000004055.V317116.R01.S.doc Version 5.2 Page 13 22 residents responded to the question “Are there activities arranged by the home that you can take part in?” 5 said “Always”; 7 said “Usually”; 4 said “Sometimes” and 1 said “Never”. One comment received said “Very limited communal activities. No participative entertainment.” Residents said that their visitors were made very welcome in the home and they could receive their visitors in the privacy of their own room or in one of the lounge areas. Some residents continued to handle their own financial affairs and others preferred to allow a chosen representative to help in that area. They were able to bring personal possessions in with them to make their rooms more homely. Generally residents said that they enjoyed the food provided. The menu offered choice. Generally residents were happy with the food and they confirmed that they could choose where they ate their meals, most preferring to take lunch and supper in the dining room on the ground floor. In the Commission for Social Care Inspection survey 17 residents responded to the question “Do you like the meals at the home?” 6 said “Always”; 4 said “Usually” and 7 said “Sometimes”. Comments included: “In view of the amount being charged by the home I feel a higher standard of food could be provided and if my relative dislikes the choices on the menu, then an alternative should be provided.” “More alternatives to the menu if the original is not is not suitable or to my taste.” “A wider choice of fresh green vegetables would be most welcome.” “The food is good and plentiful.” “The food is excellent – such a variety.” Touring the premises the inspector found some areas in the kitchen were not clean and a requirement has been made under standard 26. DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there was a complaints procedure residents and their families could not be sure that any concerns they raised would be investigated appropriately. Procedures for responding to suspicions of abuse are not held in accordance with Department of Health guidance therefore any allegations of abuse cannot be managed effectively and protection of service users cannot be guaranteed. EVIDENCE: Since the last inspection one complaint has been made to the Commission for Social Care Inspection with regard to a discharge of a resident. It was referred to the Responsible Individual to investigate. However the investigation was passed to a more junior member of staff to undertake. Even though the complaint was upheld the home did not change any of its procedures to ensure the incident was not repeated. Park Manor has a policy available to staff which deals with the action required in responding to suspicion or evidence of abuse. This policy did not make clear that in the event of any allegation being made staff must consult with the local Dorset Social Care and Health agency and refer to the “No Secrets” guidance provided by that agency. Staff spoken with did say that if they had any suspicion that abuse had occurred they would inform their line manager, however some were not sure of the procedure to follow. DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within Park Manor is generally good providing residents with an attractive, homely and safe place to live. Some of the areas of the home were not clean, which could make daily life for some residents less pleasurable. EVIDENCE: The home has a programme of routine maintenance. Records show that a variety of outside agencies have attended the home to undertake the routine maintenance of: • Fire safety equipment. • Gas installation. • Lift. • Hoists. DS0000004055.V317116.R01.S.doc Version 5.2 Page 16 The Registered Manager confirmed that electrical rewiring had just been completed at Park Manor. This meant that areas of the home needed redecorating. Residents had access to all parts of the communal areas within the home through the provision of ramps and passenger lifts. A call bell system was operational throughout the building. Touring the premises most of the home was seen to be clean and free from unpleasant odours. However, parts of the kitchen and the room where medications are stored were found to be unclean. 23 residents responded to the question “ Is the home fresh and clean?” 14 said “Always”: 3 said “Usually” and 1 said “Sometimes”. The laundry was well managed and adequate supplies of clean linen were seen to be available. DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The deployment and number of available staff was sufficient to meet the needs of the residents. Shortfalls in the recruitment of staff do not protect residents from risk. The shortfalls in some areas of training results in some care staff not being fully competent to do their jobs properly. However, sufficient numbers of care staff hold a level 2 NVQ Award (or equivalent) in care so that residents are in safe hands. EVIDENCE: Duty rotas showed that the number of care staff on duty was in line with the Residential Forum Calculator. The numbers of care staff on duty were: • 5 carers between 7am – 2pm • 3 carers between 2pm – 5pm • 4 carers between 5pm – 9pm • 2 carers awake at night and 1 sleeping (on call). DS0000004055.V317116.R01.S.doc Version 5.2 Page 18 Both the manager and her deputy’s working hours were supernumerary to the care hours mentioned above. 18 residents responded to the question “Are staff available when you need them?” 7 said “Always”; 10 said “Usually” and 1 said “Sometimes”. 10 relatives responded to the question “In your opinion are there always sufficient numbers of staff on duty?” 9 said, “Yes” and 1 said “No”. 1 relative visitor who replied “Yes” to this question added “But they do not have much time to talk and get to know residents.” The Registered Manager confirmed that 60 of care staff held the NVQ level 2 Award (or equivalent) in care. The recruitment and training files for nine members of staff were reviewed. They contained a variety of information but there were shortfalls such as: • Incomplete application forms. • Incomplete work history • Missing work permits. • References from overseas which were not accurately translated. • Lack of references. • Lack of CRB. Some members of staff were employed even though they had poor references. Since the last inspection thirty-three members of staff had left Park Manor. Eight of those had their employment terminated although there were no records kept of any disciplinary action taken. Records showed that training was inconsistent. Some staff members had induction training whilst others had no record of any training at all. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk DS0000004055.V317116.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are insufficient effective management systems, including quality assurance, in place to ensure that the home is well run in the interests of the residents. Residents are assured of sound management of their financial interests. Some practices within the home do not protect or promote the health, safety and welfare of resident or staff. DS0000004055.V317116.R01.S.doc Version 5.2 Page 20 EVIDENCE: Mrs Scanlon has the necessary qualifications and experience to run the home effectively. Staff confirm that regular staff meetings are held but minutes are not taken so that any staff who miss the meeting are kept up to date. Staff are not generally involved in the care planning of residents nor do they access care documentation, therefore they are not necessarily given a clear picture of what a resident’s needs are. The home takes some steps to review its performance. Resident surveys had been sent out but response hade been poor. No action plans or annual development plan had been developed as a result of the surveys. However, Mrs Scanlon confirmed it was her intent to provide a good service to all residents at Park Manor. Residents confirmed that they either deal with their own finances or have appointed a responsible representative to do so. This is frequently another family member. The home does hold ‘pocket money’ for some residents at their request. All monetary transactions were recorded and were seen to be up to date and accurate. Touring the premises it was noted that the cupboard on the top floor landing, used as a storeroom for cleaning materials, was unlocked and was accessible to residents. Fire records were in good order and showed that fire equipment was well maintained and staff were trained in fire safety. Some staff had not received training in moving and handling; first aid or infection control. DS0000004055.V317116.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X X 2 DS0000004055.V317116.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1) Requirement Timescale for action 14/02/07 2. OP7 15 3. OP8 14 The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, needs of the service user have been assessed by a suitably qualified or suitably trained person. (This must include the assessment of psychological and social needs.) Unless it is impracticable to carry 14/02/07 out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. (This must be made available to staff delivering the care. All aspects of care must be considered including physical, psychological and social needs.) The registered person shall 14/02/07 ensure that the assessment of the service user’s needs is kept under review and revised at any time when it is necessary to do so having regard to any change of circumstances. (A consistent, DS0000004055.V317116.R01.S.doc Version 5.2 Page 23 4. OP12 16(2)(n) 5. OP16 22 6. OP18 13(6) 7. 8. OP26 OP29 23(2)(d) 19 and Sch 2 9. OP30 18(1)(c) accurate and thorough assessment tool must be used.) Residents must be consulted about a programme of activities and the home must provide facilities for recreation. The registered person shall establish a procedure for considering complaints made to the registered person by a service user or person acting on the service user’s behalf. (This must make clear who will be dealing with the complaint.) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (The home’s written procedure for responding to suspicion or evidence of abuse must be in accordance with the Department of Health guidance “No Secrets”.) All parts of the care home must be kept clean and reasonably decorated. It is required that staff records be kept for all staff according to the Care Home Regulations Regulations 10 and schedule 2 (as amended through statutory instrument 2004 no 1770 which came into force on 26 July 2004).Timescale of 01/04/06 not met. The Registered Person must ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. (This must include training in moving and handling; first aid and common induction standards for care staff) DS0000004055.V317116.R01.S.doc 14/02/07 14/02/07 14/02/07 14/02/07 14/02/07 14/02/07 Version 5.2 Page 24 10. OP33 24(1) 11. OP38 13(4)(c) The Registered Person must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. (An annual development plan must be produced. The views of service users, family and friends and of stakeholders in the community must be sought.) The Registered Person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated.(Substances hazardous to health must be stored securely.) 14/02/07 14/02/07 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. 2. Refer to Standard OP19 OP32 Good Practice Recommendations All areas of the home should be in a good state of repair and a programme of redecoration should commence. Minutes of staff meetings should be taken and made available to all members of staff. DS0000004055.V317116.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000004055.V317116.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!