Inspection on 10/08/06 for Parkside

This inspection was carried out on 10th August 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

Parkside 04/09/07

Parkside 12/01/06

Parkside 11/07/05

Parkside 26/01/05

Parkside 20/05/04

Parkside 13/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Parkside 65 Main Road Gidea Park Romford Essex RM2 5EH Lead Inspector Diane Roberts Key Unannounced Inspection 10th August 2006 10:00 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 DS0000027871.V305772.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. DS0000027871.V305772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Parkside Address 65 Main Road Gidea Park Romford Essex RM2 5EH 01708 743110 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) Romford Baptist Church Housing Association Limited Mrs Gillian Dawn Littleboy Care Home 32 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (32) of places DS0000027871.V305772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 08/06/2006, one named Service user (Female), with Dementia, can be accommodated within the home. 12th January 2006 Date of last inspection Brief Description of the Service: Parkside is a large house in Main Road Romford that has over time been converted and extended to provide accommodation for 32 older people. The home is a care home and provides 24 hour care. The home does not provide any nursing care. The home has a mature garden and there is ample parking space for visitors. The home is in easy walking distance of local amenities and transport links. The current scale of charges is from £397.00 to £434.00 per week. There are additional costs for items such as hairdressing, chiropody and newspapers. Information is made available to prospective service users via a Service Users Guide. DS0000027871.V305772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over nine hours and was carried out as part of the annual inspection programme for this home. It was unfortunate that the manager was on leave at the time of the inspection and the deputy manager was on long term sick leave. The administrator for the home and a Senior Carer who is currently being trained to take on extra duties, assisted the Inspector throughout the day. The Inspection focused upon all of the key standards and the homes response to the last agenda for action. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Four residents, one visitor, a district nurse and four staff were spoken to during the inspection. Comment cards were received from six staff and sixteen residents. These comments were taken into account when writing the report. What the service does well: What has improved since the last inspection? What they could do better: DS0000027871.V305772.R01.S.doc Version 5.2 Page 6 Residents, relatives and staff think the home could provide a better range of activities. Some aspects of staff training have significant shortfalls, which need addressing. Recording systems, which underpin the working of the home, need to improve. This primarily relates to care assessment and planning. Shortfalls were noted in relation to the safe administration of medication. Shortfalls were noted in relation to health and safety in the home. 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. DS0000027871.V305772.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000027871.V305772.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst information is made available, this could be improved and made more user friendly. The home has a satisfactory contract in place but not all residents have a copy. Prospective residents are not all properly assessed prior to admission to the home. EVIDENCE: The home has both a Statement of Purpose and Service Users Guide in place, both of which have been reviewed this year. The Statement of Purpose is in line with regulatory requirements. The home may wish to update the staff NVQ ratio as this has improved from the numbers the home states in this document. The Services Users Guide is provided to prospective residents along with the homes brochure. Whilst the content is sound the document/sheets are not user DS0000027871.V305772.R01.S.doc Version 5.2 Page 9 friendly and not offered in a large print format. This should be reviewed along with inserting the summary page from the current inspection report. The Service Users Guide and the homes brochure states that ‘residents are expected to provide their own bedroom furniture’. This needs to be reviewed and/or clarified as the home is expected, under Regulation 16, to provide adequate furniture. The home has a satisfactory contract of residence in place. The majority of residents who commented stated that they did not have a copy of their contract. This needs to be addressed. The Manager generally undertakes all pre-admission assessments. Two admissions were case tracked. One resident was admitted the same day as referral, without an assessment from a member of the care staff and whilst the other had an assessment visit, the records were limited, incomplete and not dated or signed. Staff at the home state that they do not take emergency admissions as a rule. Residents spoken to confirmed a visit by a member of staff, at home, prior to being admitted to Parkside. The management need to improve this aspect of the admission process. Evidence from discussion shows that the home do look at whether they can meet the ongoing needs of residents, once admitted, as when appropriate residents do move to nursing homes. DS0000027871.V305772.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a care planning system in place that needs developing. Resident’s health care needs are generally met but records need to improve, to evidence this further. The medication systems in the home have some shortfalls. Resident’s privacy and dignity is respected. EVIDENCE: The home has a reasonable care planning system in place but from inspection work needs to be done to bring the system fully on board in the home. From discussion, staff are unsure of their responsibilities for assessing and planning care fully and this needs to be addressed. From case tracking residents, not all needs have been assessed or a care plan put in place. The reviews of care plans are inconsistent and limited at times with care plans and risk assessment out of date. There is some evidence that residents have been involved in their DS0000027871.V305772.R01.S.doc Version 5.2 Page 11 care plan, which is good, but the homes quality assurance questionnaires show that many residents have yet to be involved. The use of the short-term care plan, in the home’s system, needs to be developed as they are not really being used or are not short term. The care plans overall need to be more informative and show more resident choice and personal preferences. Where assessments are identifying issues/needs the records need to evidence what the care staff are doing about it. The daily notes are of a good standard but they are not all daily, as some residents may go for several days without their care or wellbeing being recorded. Staff at the home especially need to understand the duty of care to the more independent residents in the home as records for these residents were seen to be minimal and from discussion, staff were not aware of all the care needs of the individual. Residents spoken to at the home and who commented felt that overall they received the care and support they needed at the home. The inspector feels that this is generally the case, but the records at the home that underpin this need to improve. Residents comments included ‘first class care’, very satisfied with care’ and ‘staff caring and helpful’. Records show evidence of doctors, dentists and opticians visiting residents at the home in a timely manner. Records also show that residents are attending hospital appointments when required. Weight monitoring is being done inconsistently and new residents are not weighed upon admission. Residents who have identified dietary care needs did not have a nutritional risk assessment and care plan in place. Residents with identified care needs in relation to pressure sore prevention were seen to have no risk assessment or care plan in place although there were clear care needs and district nurse referral. Some residents were seen to have specialist beds in place. Records show evidence of chiropodist visiting residents on a regular basis. District Nurses visiting the home speak positively regarding the standards of care given and feel that the staff know the residents well. They feel that they get called in a timely manner and proactively. The Practice Nurse also visits every Friday. The home uses a blister pack and bottle to mouth system for the administration of medication. This system was inspected. Slips of paper were seen with the medication pots, indicating pre dispensing, which is not acceptable. This was discussed with senior care staff and it is apparent that the people dispensing are not always administering and often giving pots of tablets for other staff to give. The person dispensing must also administer and take responsibility and sign for the medication as having been taken. This needs to be addressed. The signing in and checking over and returns systems fine were kept in good order with clear records. It was positive to see some residents self-medicating, but no risk assessments are in place. The MAR sheets were in good order but a DS0000027871.V305772.R01.S.doc Version 5.2 Page 12 lot of handwritten prescriptions were noted that relate to the supplying pharmacy. The staff need to sort this out with the pharmacy to reduce this and therefore reduce the risk of errors. Staff are administering homely remedies but report that there is no homely remedy policy in place. Upon inspection the home do have a bought in policy but staff are unaware of this and it may not be suitable for the needs of the home. This was discussed with senior care staff. Dates of opening should be recorded on liquid medication and eye drops etc. to enable a full audit if required and for disposal times. No controlled drugs are currently being used in the home and no CD storage is available. This should be reviewed; as it is relatively common practice for CD’s to be used in care homes and the correct storage should be available should that occur. Training records show that no staff have received medication training although the PIQ states that this is planned. Residents spoken to are very happy with how staff treat them in relation to their privacy and dignity. Interaction observed and heard between staff and residents was very caring and appropriate. Residents who commented said that they got privacy if they needed it. Residents at the home state that the laundry service is very good and all their clothes are well cared for. DS0000027871.V305772.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social activities in the home need to improve. Residents have good contact with family and friends. As far as possible, residents are helped to exercise choice and control over their lives. The food provided is generally good and enjoyed by residents. EVIDENCE: The administrator at the home tends to lead the social programme with occasional input from volunteers. One or two activities may be planned per month and these may include a quiz or a board game. Staff report that activities such as board games and exercises have tailed off so they have been stopped for the time being. Records and care plans show that there is a limited acknowledgment of resident’s social preferences and past hobbies etc. The activity programme is not based upon residents’ preferences and the majority of residents who commented felt that this was the only thing lacking in this home. Residents enjoy the church services but are also keen to get out DS0000027871.V305772.R01.S.doc Version 5.2 Page 14 of the home for short outings. The home has just been granted the money for a new minibus with a tail lift, which will facilitate this more. No records are maintained which show who attended activities offered. From the homes own satisfaction questionnaires, the main issue for both residents and relatives is the social activities programme/outings and would improve the quality of life for residents. Residents spoken to say that they had choice as to how they spent their day in the home and records show that resident’ choices are respected in relation to their healthcare. The home has an open visiting policy and residents spoken to were happy with this and felt that their visitors were made welcome. Visitors are able to stay for a meal if the resident wishes. The home does have some information on local advocacy services but this needs to be developed and made available to residents. Overall residents are very happy with the meal service at the home. There are the occasional issues raised by residents, but from discussion with the staff, they are keen to provide the residents with meals that they are happy with. From discussion, residents are keen to be involved in menu planning. All the food is home cooked and was seen to be of a good quality and quantity. A good range of choice is available at breakfast. Lunch was seen to be a relaxed and dignified affair with residents able to self serve themselves where possible and the tables were nicely laid. Residents with specific dietary needs are well catered for and those with a limited appetite are individually cared for with staff providing items that would encourage them to eat. DS0000027871.V305772.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place to help ensure that concerns and complaints will be listened to and acted upon. The home has systems in place, which help to ensure the protection of vulnerable adults from abuse but training provision needs to be reviewed. EVIDENCE: The home has a satisfactory complaints procedure in place. This is displayed in the main hallway and is in the Service Users Guide. A recording book is in place for official complaints and none have been since November 2004. Compliments cards were seen from relatives who commented on ‘lovely meals’ ‘patience of staff’, ‘high professional standards’, ‘friendly caring atmosphere’ and ‘understanding and concern for residents and family’. Residents spoken and from comment cards were aware of the complaints procedure and who they would go to if they wished to raise a concern. Minutes of residents meetings also show that residents raise concerns and queries through this method. The home has a bought in policy on adult protection, local guidance and the homes own information and guidance. Whilst these are all acceptable, it is recommended that these are pulled together and streamlined so it is clear to staff what they need to understand and do, if required. DS0000027871.V305772.R01.S.doc Version 5.2 Page 16 Training records show significant gaps in staff training on adult protection and this needs to be addressed. DS0000027871.V305772.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well decorated and generally safe, although the home needs to address shortfalls in relation to fire safety. The home is clean and hygienic. EVIDENCE: The home is currently undergoing a five-year refurbishment plan and the written plan is available for inspection. Refurbishment seen on the day of the inspection has been completed to a very high standard. Bedrooms are redecorated as they are available and at that time, wardrobes and other furniture are being replaced. Residents spoken to and from comment cards are very happy with the fabric and décor of the home. Comments included ‘nicely furnished and decorated’. A new hot water system has been installed with minimal disruption to residents. Good records are available which show the checking and adjusting of hot water valves. Some valves still need replacing and home are still getting to DS0000027871.V305772.R01.S.doc Version 5.2 Page 18 grip with the new hot water system. One hot water outlet tested, on the day of inspection was at 48oc. It is recommend that the home review the timing of how often they test, which is currently quarterly, to help reduce the risk of scalding. The home has three very pleasant communal areas to sit in, including a conservatory with blinds. The dining room been redecorated since the last inspection and the doors widened and adjusted to the conservatory and to allow better access. The home has a nice garden with seating areas, one completed in conjunction with a local primary school. The management has obtained planning permission to extend at the rear of the home and add three further beds. This will help reduce the number of double rooms in the home. Good maintenance records are in place for each room in the house, including A fire risk assessment has been done and approved by a local fire officer. This was completed in January 2005 and a review is recommended. Records evidence weekly fire alarm tests but do not evidence checking of the emergency lighting system. This needs to be addressed. Records are in place, which shows that the home holds regular fire drills with its staff. Maintenance certificates for the fire alarm and emergency lighting were seen to be out of date and this needs to be addressed. Maintenance certification for the fire extinguishers was seen to be in order. Upon inspection, the home was seen to be very clean and no odours were noted. Residents who comment said that the home was always clean and fresh. Staff training records show that no staff have up to date infection control training in place and this should be addressed. DS0000027871.V305772.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff currently meet the services users needs. Residents are in safe hands with staff at the home, many of who have NVQ qualifications. The home has generally sound recruitment policies and procedures. Whilst the home is providing and encouraging staff training, there are significant shortfalls. EVIDENCE: Two weeks of staff rotas were inspected. These showed that generally five staff are on in the morning, four in the afternoon and two on at night. At some points during the day, mainly afternoons, the staffing levels often drop by one person for an hour. The rota must show the designation of all the staff and the person in charge on each shift – this was not always apparent. Whilst the rotas evidence flexible staffing, the home must keep the staffing levels under review to ensure that the needs of residents are met. Residents, who commented, mainly said that staff were usually available to them when they needed someone. Some of the staff who commented were concerned that morning and evening kitchen duties were taking them away from the needs of residents and also limiting the availability of breaks during the late shift. DS0000027871.V305772.R01.S.doc Version 5.2 Page 20 The management at the home encourages staff to undertake NVQ qualifications. Records show that 63.6 or the care staff have either and NVQ level 2 and 3.qualifications. Of the 14 staff qualified, 7 have NVQ level 3. Five staff files were inspected at random. These were seen to be in good order with the appropriate checks undertaken and documentation in place. The home was seen to have a very basic application form, which does not cover the Rehabilitation of Offenders, gaps in employment and last employer references. This was discussed and the home may wish to update their application form. No interview records are kept and this is recommended. The manager has set up an induction programme for new staff at the home. This lasts six weeks and includes infection control, health and safety, risk assessments, POVA etc. At the current time, records seen show that the programme does not cover any aspects of care, including privacy and dignity, and this should be reviewed. It is also understood that the programme is not currently linked to Skills for Care. No current records were available for inspection. Staff spoken to confirmed shadowing shifts, when starting work at the home and a basic induction but were unaware of the file and six-week programme. Overall the induction programme at the home requires a review. Training records were submitted for inspection and these show significant gaps in staff training with regard to both statutory and additional training. Fire safety training is particularly poor. These shortfalls need to be addressed and a planned training programme put in place. DS0000027871.V305772.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is of good character, suitably qualified and fit to run the home. The home has a quality assurance programme in place, which could be developed further. Resident’s financial interests are safeguarded. The home has a staff supervision system in place that is developing. Whilst the health and safety of residents and staff is promoted, some shortfalls were noted. DS0000027871.V305772.R01.S.doc Version 5.2 Page 22 EVIDENCE: It was not possible to meet the Registered Manager on the day of the inspection. Mrs Littleboy has recently been successfully registered with the CSCI, as the manager for the home. Staff speak positively about her and feel that she is approachable. The home has a quality assurance system in pace which consist of satisfaction questionnaires for both residents and relatives. These were inspected and had been recently completed, although there was no date on them. Overall the questionnaires are good and cover a wide range of subjects. The results were generally positives for both groups. At the current time there is no analysis of the results or action plan. The management of the home also undertake a health and safety inspection twice a year and keep records kept and action plans for this. This could be developed further to cover other areas of the home, including care records, medication etc. The home holds some money in safekeeping for service users. Records are kept of all expenditure and receipts are also kept. There is a check made of all records and money held to ensure that entries are correct at all times. The manager has put a staff supervision in place and this was evident in the staff files. Records show that at the current time there is no set system in place or a consistent approach. The content of the supervision sessions was seen as good and covered all the required areas. Annual appraisals were also seen in the staff files. A more consistent approach to supervision is needed. The home has a health and safety policy in place. Safe working practice risk assessments have yet to be done in the home and these were discussed. Safety and maintenance certification for equipment and fixtures in the home were randomly inspected and found to be in order but no current lift safety certificate was available. Accident records were checked in relation to the care records case tracked. These records were in good order and in sufficient detail, they also related to the individual in their care records. It was noted that the windows upstairs do not have restrictors in place and the home should undertake a risk assessment with regard to assessing the need to put these in place. DS0000027871.V305772.R01.S.doc Version 5.2 Page 23 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 DS0000027871.V305772.R01.S.doc Version 5.2 Page 24 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 Requirement The registered person must ensure that all residents are assessed prior to admission to ensure that the home can meet all their needs. The registered person must ensure that residents have care plans in place for all their care and social needs. Care plans must be kept under review and where possible involve the resident or their representative. The registered person must ensure that residents’ health care needs are met in relation to nutritional care including weight monitoring and risk assessments, pressure sore prevention and manual handling. The registered person must ensure the safe handling of medication in the home in relation to pre dispensing, storage, homely remedies, selfmedicating and staff training. The registered person must consult with residents about their social interests and arrange DS0000027871.V305772.R01.S.doc Timescale for action 30/09/06 2 OP7 15 14/10/06 3 OP8 13 14/10/06 4 OP9 13(2) 30/09/06 5 OP12 16 (m) and (n) 30/09/06 Version 5.2 Page 25 a programme of activities based upon this consultation. Records must be maintained. 6 OP18 13 (6) The registered person must make arrangements by training or other measures to prevent resident suffering abuse. The registered person must make adequate arrangements against the risk of fire – in relation to staff training, reviews of risk assessments and the checking and maintenance of equipment. The registered person must undertake a risk assessment in relation to the frequency of testing hot water outlets in the home. The registered person must provide staff in numbers that will meet residents’ needs and keep those numbers under regular review. The registered person must provide staff with training appropriate to the work they are to perform – in relation to induction, statutory and additional training. The registered person must continue to develop the quality assurance programme in the home. The registered person must ensure the health and safety of residents and staff in the home – in relation to safe working practice risk assessments, the provision of window restrictors and provision of a passenger lift safety certificate. 30/09/06 7 OP19 23 (4) 30/09/06 8 OP19 13 30/09/06 9 OP27 18 30/09/06 10 OP30 18 30/10/06 11 OP33 24 30/10/06 12 OP38 13 30/09/06 DS0000027871.V305772.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The registered person should review the Service Users Guide in relation to format, user friendliness and content with regard to the provision of bedroom furniture. The registered person should ensure that residents have a copy of their contract/terms and conditions of residence. The registered person should make information on advocacy services available to all residents. The registered person should provide infection control training for staff. The registered person should keep records of staff interviews and give consideration to updating the homes’ staff application form. The registered person should put a formal staff training plan/programme in place. The registered person should continue to develop a formal staff supervision programme in the home. 2 3 4 5 6 7 OP2 OP14 OP26 OP29 OP30 OP36 DS0000027871.V305772.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000027871.V305772.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!