Inspection on 12/06/06 for Pennefather Court

This inspection was carried out on 12th June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pennefather Court 17/09/08

Pennefather Court 26/09/07

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

CARE HOME ADULTS 18-65 Pennefather Court Croft Road Aylesbury Bucks HP21 7RA Lead Inspector Joan Browne Unannounced Inspection 12th June 2006 14:30 DS0000067529.V312491.R01.S.doc Version 5.2 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 DS0000067529.V312491.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 Adults 18-65. 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. DS0000067529.V312491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pennefather Court Address Croft Road Aylesbury Bucks HP21 7RA 01296 484810 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) Sanctuary Care Caroline Rush Care Home 14 Category(ies) of Physical disability (14) registration, with number of places DS0000067529.V312491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 1. That as of the 29th of November the home is registered to provide care for two Service Users over the age of 65. That this condition relates to two specific service users and should they leave the home, for whatever reason, the home must notify CSCI and this condition will cease to apply. Date of last inspection 23rd January 2006 Pennefather Court is a care home providing personal care and accommodation for fourteen residents with a physical disability. On the day of the inspection there were thirteen residents living in the home. Sanctuary Care owns the home. The home is located in Aylesbury in a quiet cul-de-sac close to shops, pubs the post office and other amenities. Public transport is easily accessible. The home was opened in 1989 and consists of a two-storey building. The ground level accommodates residents and all bedrooms are single occupancy. Two of the bedrooms have en suite facilities. There is a patio area, which is easily accessible by residents. The weekly current scale of charge is £831.96 DS0000067529.V312491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home which took place on 12 June 2006 from 14.30 pm to 21.15 pm. The Acting manager and senior support worker facilitated the visit. The inspection consisted of discussions with residents, staff and one relative who was visiting the home at the time of the inspection. Care documentation and records were examined and a tour of the building was carried out. The evening meal was observed. The requirements and recommendations from the previous inspection were discussed. Comment cards were received from six relatives, one care manager and the general practitioner. Specific comments received from relatives and health and social care professionals in relation to the day-to-day operation of the home and residents’ health needs were discussed with the acting manager for appropriate action to be taken. Overall relatives and health care professionals were satisfied with the provision of care. Some residents spoken to were complimentary about staff and felt that the staff team supported them to lead an independent and fulfilled life. A large number of residents maintain close links with the local church and are regular churchgoers. Feedback was given to the acting manager and senior support worker on the findings of the inspection. What the service does well: What has improved since the last inspection? As from 1 April 2006 the home was taken over by a new provider. Five bedroom carpets have been replaced. The broken clinical waste bin has been replaced. A protocol for the administration of Alenoronic Acid medication that is used in the treatment of osteoporosis has been developed. The home has DS0000067529.V312491.R01.S.doc Version 5.2 Page 6 developed a supervision framework to ensure that all staff receive regular supervision. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000067529.V312491.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000067529.V312491.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that prospective residents are assessed before being admitted to the home to ensure that the home could meet individuals’ assessed needs. EVIDENCE: Since the last inspection the home has not had any new admissions to the home. The acting manager confirmed that she was in the process of admitting a new resident to the home. It is the practice in the home that a senior member of staff would assess any prospective resident before being admitted. The prospective resident is also invited to spend a day in the home to meet with residents and staff and to get a feel of the home. DS0000067529.V312491.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are encouraged to make decisions about their lives and to take risks thus maintaining an independent lifestyle. However, care plans examined need to be more detailed and reflect any changes in residents’ health and social care needs to ensure continuity of care. EVIDENCE: Two care plans were examined. It was evident that yearly care plan review meetings had taken place. The residents along with the home’s staff and care managers were involved with the process. It was noted that plans did not always reflect the changing needs of individuals. As a result the monthly tracking and summary sheets used to evaluate individuals’ care and health needs did not always inter-relate and lacked detailed information. Daily records were predominantly orientated towards recording physical care and did not refer to residents’ participation in activities, their interaction with staff and mood. DS0000067529.V312491.R01.S.doc Version 5.2 Page 10 Moving and handling risk assessments were in place and reviewed yearly. However, the process of the review was not recorded. In one particular resident’s moving and handling risk assessment there was no information recorded on how staff should be assisting the individual. However, a member of staff was able to describe the level of support that was being provided to the resident. Residents spoken to confirmed that staff respected their rights and empowered them to make decisions. One particular resident expressed a wish to move on to independent living. The staff team supported this decision and plans were being made for the individual to be re-housed with the appropriate care package. Those residents who were not able to make decisions get assistance from their advocates to help them with their decision making. It was noted that one resident was using the services of an advocate. The advocate’s role is to simplify complicated issues in a way that the resident could understand and to assist the individual with expressing any concerns that they might have. It was noted that one resident was able to handle their own financial affairs. Four residents were subject to power of attorney and one subject to guardianship. The home has a system in place for dealing with residents’ money that is held in the home and is separate from the home’s petty cash system. Written records of transactions are maintained and receipts are retained. Records examined were in order. Residents are encouraged to take risks which is based on them developing and maintaining independence. Staff spoken to confirmed that residents are encouraged to prepare their own snacks at lunchtime. Some residents were observed making drinks and offering to make drinks for those residents who were not able to. On the day of the inspection one particular resident went out independently to the shops in her electric wheelchair. The home has a missing person’s procedure in place which all staff are aware of. DS0000067529.V312491.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are able to choose their own lifestyle and to be involved in any decision that may affect them thus promoting them to be independent and to be part of the local community. EVIDENCE: A tutor visits the home weekly to facilitate literacy classes. One particular resident spoken to was attending drama classes. There were no residents who were attending college or in employment at the time of the inspection. Residents are seen very much as part of the local community. Some have close links with the local church and are invited to church functions. One particular resident is a keen dart player and is a member of the local dart club and is supported by staff members to pursue this hobby. The staff team support residents to maintain family links and friendships. Relatives and friends are able to visit at any time. A relative who was visiting the home at the time of the inspection confirmed that overall the provision of care was satisfactory and staff always made visitors feel welcome and were DS0000067529.V312491.R01.S.doc Version 5.2 Page 12 hospitable. Residents are able to develop and maintain intimate relationships with whom they wish to. The staff team would facilitate residents to access specialist guidance to assist them to make appropriate decisions. Staff are expected to knock and wait for a reply before entering residents’ bedrooms. Residents if they wish to are provided with keys for their bedroom doors and the main front door. Staff do not open residents’ letters unless they are asked to do so by those residents that require assistance. Residents’ preferred form of address was documented in the care plans. Staff were observed interacting with residents in a sensitive and caring manner. Some residents choose to spend time alone and enjoy their own company. Residents do not have responsibilities for housekeeping tasks. Arrangements were in place for residents to smoke in their bedrooms with the appropriate risk assessments in place. Staff members escort those residents who enjoy having a drink to the pub as part of their social activity outing on a regular basis. Residents are provided with meals three times daily. Snacks are readily available throughout the day. Those residents who are able to prepare their own snacks are encouraged by staff to do so. The evening meal was observed which consisted of two choices of either sausages or chilli cobbler with mashed potatoes and carrots. Dessert was ice cream or chocolate pudding. The meal was tasty and appeared to be a relaxed and social occasion. Residents chatted with each other during the meal. Staff were observed offering assistance to those residents who needed assistance in a discreet and sensitive manner. Residents confirmed that meals served were tasty and portions were adequate. Staff and residents were pleased that the chef’s position had been filled after being vacant for a very long time. This meant that staff were able to spend more time with residents. A discussion was held with the chef and she was keen to ensure that residents’ are offered a healthy diet that meets with their cultural and dietary needs. One particular resident was concerned that the evening meal was not being served at the appropriate time which was six o’ clock. This concern was passed on to the acting manager to be addressed. DS0000067529.V312491.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff do not always appear to be aware of residents’ medical and health condition. This could have an impact on resident’s care. Weaknesses and inconsistencies identified in staff’s medication practice could pose a risk to residents. EVIDENCE: Residents confirmed that personal care was provided sensitively, taking into consideration their wishes and preference on gender care. It was noted that residents were appropriately dressed with attention to detail. Staff spoken to confirmed that those residents whose moving and handling risk assessments required two members of staff to assist with moving and handling was always followed to ensure residents’ safety. The home provides aids and equipment such as, overhead hoists and sliding sheets to maximise residents’ independence. Staff and other health care professionals such as the district nurse, the general practitioner, and physiotherapist were supporting residents to maintain their physical and health care needs. The district nurse was providing continence aids and equipment to those residents with continence problems. It was noted that continence assessments developed for two particular residents needed to DS0000067529.V312491.R01.S.doc Version 5.2 Page 14 be more detailed. For example, the assessments did not indicate the level of assistance that staff should provide. Staff escort residents to doctor’s appointments and hospital visits. Some health and social care professionals felt that there were times when staff members escorting residents for medical appointments were not familiar with the resident’s condition or are able to give an account of their general health. A clear procedure needs to be in place to ensure that staff escorting residents are aware of residents’ problems and are able to report on their condition. It was also noted that one particular resident was ‘experiencing epileptic episodes.’ There was no agreed plan of care in place outlining how staff should be meeting the identified need. The home uses the Manrex monitored dose medication system. The medication administration record (MAR) sheets were examined and several gaps were noted. The blister packs were checked and the tablets were not in the packets. It was evident that the tablets were administered but not signed for. In other instances staff did not use the appropriate code to denote reason for omission. It was noted that a handwritten entry for Trimepthropin medication, which is an antibiotic was not signed and dated by two staff members. As a good practice any handwritten entry on the MAR sheet should be checked and signed by a second staff member. Inhalers in use did not record the date of opening. As a good practice the date should be recorded on inhalers in use to ensure that the recommended time given to keep once opened is followed. It was noted that Lactulose solution, which is an aperient, was recorded on the MAR sheet as: ‘give as directed’. Entries on the MAR sheets should state clearly the frequency and dosage of medication to be administered. The manager should ensure that the MAR sheets are regularly monitored. Staff’s competencies in the administration of medication must be assessed regularly to ensure that staff are administering medication in accordance with the home’s medication procedure. DS0000067529.V312491.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has a complaints procedure in place to ensure that residents and relatives are listened to. However, the home’s recruitment policy needs to be more robust to protect residents from any potential harm. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Information recorded on the pre-inspection questionnaire indicated that the home had not received any complaints. Residents spoken to were aware of the home’s complaints procedure. The Commission has not received any information concerning allegation of potential abuse to residents. Some staff spoken to confirmed that they had undertaken training in the protection of vulnerable adults. It was difficult to ascertain if the recently appointed staff members had undertaken training in the protection of vulnerable adults. There was no evidence of a written induction programme in place in staff’s files examined. This omission has the potential of putting residents at risk of being harm. It is acknowledged that the home has an adult protection and whistle blowing policy in place. DS0000067529.V312491.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Issues relating to the environment that have been highlighted within this report and require attention need to be addressed to ensure that residents’ safety and well-being are not compromised. EVIDENCE: The home’s premises are suitable for its stated purpose. It is accessible, and meet residents’ individual and collective needs. It is located in Aylesbury in a quiet cul-de-sac close to shops, pubs, the post office and other amenities. It was noted that the carpet in the corridor near to the laundry room and the front of the building was covered in fluff this made the premises look unkempt. The home’s cleaner works four days a week. It would be advisable that arrangements are put in place to maintain the cleanliness of the premises when the cleaner is not available. The home complies with the fire authority requirements. It was noted that the home had not received a recent visit from the local environmental health authority. DS0000067529.V312491.R01.S.doc Version 5.2 Page 17 The home was recently taken over by a new care provider and was going through a transition stage. At the last inspection a requirement was set for the following maintenance work to be carried out: • • Chipped paintwork on corridor walls, skirting boards and doorframes required painting Some bedrooms were in need of redecorating and bedroom furniture was worn and in need of replacing. This requirement had not been complied with and is repeated. It is acknowledged that the new provider had submitted a pro-forma invoice to the home listing some maintenance work that was due to take place. During a tour of the building some housekeeping issues were identified as needing attention. Arrangements must be made for the shrubs to be cleared from the pathway around the home and patio area. The broken furniture stored at the back of the building and in one of the satellite kitchens must be removed. A cleaning schedule must be introduced in the satellite kitchens to ensure that the microwaves and other utensils are cleaned after use. The home was free from offensive odours on the day of the inspection in the communal areas. However, in one particular bedroom there was a strong odour. Arrangement must be made for the shampooing of the carpet to be increased. If odour persists the floor covering must be replaced. It was noted that a new washing machine had been installed with the specified programming ability to meet disinfection standards. The sluice room has an appropriate sluicing disinfector fitted. A requirement was made at the last inspection that the clinical waste bin must be replaced with one that has been fitted with a lock. The requirement had been complied with however, the old bin had not been removed. Arrangements should be made for it to be removed. DS0000067529.V312491.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Arrangements should be made to ensure that the staffing levels in the home are regularly reviewed to reflect residents’ changing needs. Some weaknesses in the home’s recruitment procedure have the potential to put residents at risk of being harm. EVIDENCE: The home employs twenty-seven care staff of which six have achieved National Vocational Qualification (NVQ) at level 2. The home ensures that there are five staff on duty covering the morning shift. This number is reduced to four staff in the afternoon. One waking carer and a senior support worker sleeping in covers the night shift. Staff are expected to provide one to one activity with those residents who are no longer able to attend the local day centre. The home aims to ensure that residents are provided with up to three hours activity time weekly. However, this has not always been achievable because there are times when the home has not been fully staffed. It was noted that the home does not have a structured activity programme in place. Some residents spoken to preferred to spend their time outside the home visiting the local pubs, shops, and the leisure centre and attending shows at the local civic centre. Residents spoken to were missing not being able to attend the day centre. A particular relative was concern that the home was not honouring the agreement made with residents that more DS0000067529.V312491.R01.S.doc Version 5.2 Page 19 activities would be provided in-house when the attendance at the day centre ceased. Arrangements should be made to ensure that the staffing levels in the home are regularly reviewed to reflect residents’ changing needs. Staff meetings take place regularly and records of minutes of meeting were available. The staff’s files for the four recently appointed staff members were examined. Enhanced Criminal Record Bureau (CRB) clearances were in place. Two written references were obtained and application forms were completed along with interview notes. Declaration of health checks and terms and conditions of employment were in place. Of the four files examined there were up to date photographs on three files to confirm proof of identity. The authenticity of references from employers on three files was not evident. However, on the fourth file the reference from the employer had an official stamp. Work permits seen appeared to be current. It was noted in one employee’s file that the most recent employer, which was an employment agency was not recorded on the application form. However, the employee used the agency as a referee. It is required that the home must ensure that where references are obtained from employers a company stamp on references be obtained or a complimentary slip is attached to substantiate the authenticity of the reference. The four new members of staff confirmed that they had undergone a two week induction programme. However, there was no written induction programme in place. The acting manager confirmed that work was in progress to have one developed. It is acknowledged that of the four staff files examined there were copies of certificate in three staff members’ files to verify that these staff members had undertaken training in equality and valuing diversity and moving and handling. It was noted that the training schedule for the new financial year had not yet been agreed. As a result the home was not able to confirm when mandatory training updates for staff members would be facilitated. DS0000067529.V312491.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs to further develop and formalise its audit systems to ensure that the home is run in the best interests of residents. The health and safety systems in place need to be improved to ensure that residents’ safety is not compromised. EVIDENCE: The registered manager is on six months maternity leave. The team leader has been promoted to act as manager in her absence. The acting manager has been working in the home in a supervisory capacity for approximately fifteen years. She holds the National Vocational Qualification (NVQ) assessor’s award and is very experienced with working with the client group. Three senior support workers support the acting mangers with the responsibilities of running the home to ensure that residents’ interests are well looked after and the home is well run. An annual residents and relatives survey takes place. However, the outcome of the recent survey undertaken with agreed actions was not available. The DS0000067529.V312491.R01.S.doc Version 5.2 Page 21 home needs to further develop and formalise its own internal audit systems to ensure that the home is run in the best interests of residents. The fire records examined indicated that the fire panel and emergency lights were checked weekly. A recent fire drill was held on 7 May 2006. Fire training was held on the 8 May 2005. The fire equipment was serviced on 11 August 2005. It was noted that all senior staff had undertaken first-aid training. The central heating system and boiler were serviced on 26 April 2006. It was noted that there was a problem with the heating system, which took some time to be remedied. The home failed to report this incident to the Commission. Any event in the care home that adversely affects the well-being or safety of residents must be notified to the Commission under Regulation 37 Food temperature records identified that staff have not been consistent in recording the hot food temperatures. Gaps were noted on the record sheets. It is required that food temperatures be recorded daily in line with the food standards guidance. It was noted that food handling and hygiene training for staff needed to be updated. It was noted that all senior staff had undertaken first-aid training. The electrical hardwiring certificate was updated on 15 May 2006. The bath and mobile hoists were serviced on 12 May 2006. The call bell system was serviced in October 2005. A requirement was made at the last inspection that a risk assessment must be developed for escorting residents on shopping trips and outings. This requirement had not been complied with and is being repeated. DS0000067529.V312491.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 1 X 2 X X 2 X DS0000067529.V312491.R01.S.doc Version 5.2 Page 23 Yes 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 YA6 Regulation 15(2)(b) Requirement The manager must ensure that care plans are detailed and reflect residents’ changing needs and interrelate with the monthly summary and tracking sheet. The manager must ensure that staff administer medication in accordance with the British Pharmaceutical Guidelines. All staff who administer medication must have their competencies regularly assessed. Timescale for action 31/08/06 2. YA20 13(2) 31/08/06 3. YA24 4. YA24 5. YA24 6 YA24 23(2)(b)(d) The manager must ensure that chipped paintwork on corridor walls skirting boards and doorframes be painted. 16(2)(j) The manager must ensure that food temperature records are maintained in line with the food standards guidance. 23(2)(d) The manager must ensure that broken furniture stored at the back of the building be disposed of. 23(2)(d) The manager must ensure that bedrooms in need of decorating are attended to and worn DS0000067529.V312491.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 Version 5.2 Page 24 bedroom furniture be replaced. 7 8 YA30 YA24 23(2)(d) 16(2)(k) The manager must ensure that shrubs be removed from the pathway and patio area. The manager must increase the cleaning of the bedroom carpet with the odour. If odour persists the floor covering must be replaced. The registered manager must ensure that weaknesses identified in the home’s recruitment procedure are addressed. The registered manager must ensure that a risk assessment be developed for staff escorting residents on outings and shopping trips. (Previous timescale of 31/05/06 not met). The manager must ensure that any event in the care home that affects the safety of residents must be notified to the Commission. 31/08/06 31/08/06 9. YA34 Schedule 2 (1) 19(1) 31/08/06 10. YA42 13(4)(b)(c) 31/08/06 11 YA42 37(1)(c) 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 1. YA18 It is recommended that the manager should develop a procedure for staff escorting residents for medical appointments and hospital visits to ensure that staff are well informed of the resident’s condition. It is recommended that the manager should ensure that the dates are recorded on inhalers when opened. It is recommended that the manager should ensure that ‘As directed’ entries are not recorded on MAR sheets. 2. YA20 3. YA20 DS0000067529.V312491.R01.S.doc Version 5.2 Page 25 4 YA24 5 YA33 6 YA33 7 YA39 It is recommended that the manager should introduce a cleaning schedule in the satellite kitchens to ensure that microwaves and other utensils are maintained. It is recommended that the manager should develop a structured activity programme to meet residents’ social needs. It is recommended that the manager should ensure that the staffing levels in the home are regularly reviewed to reflect residents’ changing needs. It is recommended that the manager should develop an internal audit system to ensure that the home is run in the best interests of residents. It is recommended that the manager should ensure that daily food temperatures are recorded before serving hot food. 8 YA42 DS0000067529.V312491.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000067529.V312491.R01.S.doc Version 5.2 Page 27 - 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. 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