Inspection on 23/06/06 for Pinhay House

This inspection was carried out on 23rd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Pinhay House 21/09/07

Pinhay House 04/01/06

Pinhay House 28/07/05

Pinhay House 20/01/05

Pinhay House 29/07/04

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 Pinhay House Pinhay House Rousdon Lyme Regis Dorset DT7 3RQ Lead Inspector Michelle Oliver Key Unannounced Inspection 23rd June 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 Pinhay House DS0000022010.V293204.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. Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinhay House Address Pinhay House Rousdon Lyme Regis Dorset DT7 3RQ 01297 445626 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) The Pinhay Partnership Mrs Carole Jane Hodges Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th July 2002 Brief Description of the Service: Pinhay House is owned by The Pinhay Partnership. It provides accommodation and personal care for up to 25 older people who may suffer from mild to moderate dementia. The home is unable to care for people with severe dementia, or people who may display aggressive or unsociable behaviour. The property is a large converted Grade II listed mansion house standing at the end of a long drive approximately 2 miles from Lyme Regis. Bedroom accommodation is situated on the ground and first floors. There is a stair lift to the first floor but there are then further steps that residents may have to negotiate. Rooms at the front of the house benefit from sea views and other rooms overlook the surrounding countryside. Pinhay House has a large entrance hall, lounge/dining room and various quiet sitting areas throughout. Many of the rooms retain interesting period features and are large, bright and airy. The home’s statement of purpose and service user guide is available at the home, which includes details about the philosophy of the home, a statement of terms and conditions and details about living at the home. This is made available to all potential residents before they make a decision about living at the home. A copy of the most recent inspection report is available on request. Information received from the home indicates that the current fees are £306£580 weekly. Services not included in this fee include hairdressing, chiropody, toiletries and personal shopping, incontinence aids, newspapers and transport at 30p per mile. Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Tuesday 23rd and Wednesday 24th June 2006 over a period of 9.5 hours. The provider was present throughout the inspection. Some positive informative discussion and exchange of information took place. During the inspection the inspector case tracked 3 residents, which helps us to understand the experiences of people using the service. A number of other residents were met and spoke with during the course of the day. The inspector also spent a considerable time observing the care and attention given to residents by staff. Several staff were spoken with during the day. Prior to the inspection 11 surveys were sent to residents to obtain their views of the service provided; 2 were returned. Comments were in the main satisfactory with the majority of the respondents confirming that they ‘usually’ receive the care and support they need. 14 staff were sent surveys in order to hear their confidential views; 7 were returned. The staff responses indicate that staff feel supported in their role. 5 health and social care professionals were also contacted prior to the inspection including 3 GPs and 2 district nurses The inspector toured the premises and a sample number of records were inspected which included care plans, medication records/procedures, staff recruitment files and fire safety records. The manager had completed a pre-inspection questionnaire and the inspector appreciated the preparation undertaken by the manager to assist with this inspection. Finally the outcome of the inspection was discussed with the provider and care supervisor. What the service does well: Staff treat residents as individuals aiming to make their lives as independent and fulfilling as they can. All residents spoken with praised the care they received from the staff and said they were very happy living at the home. One said “We are all looked after very well”. Staff are keen to ensure the well-being and comfort of the residents and treat them with respect and kindness. The home was very clean and fresh; residents said this was always the case. Residents praised the quality and variety of the meals served at the home. Residents are supported and stimulated to take part in the homes’ comprehensive activities programme at the home Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Pinhay House DS0000022010.V293204.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 Pinhay House DS0000022010.V293204.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): OP3 & 6 Quality in this outcome is adequate. This has been made using available evidence including a visit to the service. Residents benefit from a generally good admission practice. Some improvement is required to ensure that all assessments are sufficiently detailed to reflect residents’ needs. EVIDENCE: Residents spoken to said that they were given enough information about Pinhay House before making a decision to make it their home. Some residents could not recall the process but were happy living at the home and with the care they receive. The home owner said that family members and potential residents were welcome to visit the home, ask any questions, meet the other residents, if they are agreeable, and have a meal if they wished. Two residents returned questionnaires before this visit; all said that they had been given sufficient information about the home before making a decision to live there. Three residents’ plans of care were looked at during this visit. The assessments undertaken before the residents decided to make Pinhay House their home lacked detail and did not include sufficient information on which to compile Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 9 care plans For example, the assessment for a recent admission did not include details about foot care, emotional well being, hobbies, family details or social aims and objectives. One questionnaire from a resident stated “we have a verbal contract at the moment because we are waiting to change rooms. We are happy with this situation. The minute we walked into the home we knew it was the right one”. Another stated that they have not received a contract, but had been provided with sufficient information about home. Included in the service user guide is a statement of terms and conditions which residents read, agree to and sign. Pinhay House DS0000022010.V293204.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): OP 7, 8, 9 & 10. Quality in this outcome is adequate. This has been made using available evidence including a visit to the service. Improvement is needed in the care planning process at the home. Medication is generally well managed but attention is needed in three areas. Residents’ privacy and dignity are generally met and promoted by the staff and management at the home but urgent attention is needed to deal with a current situation at the home. EVIDENCE: All residents have a plan of care but not all personal needs have been identified. Three residents’ care plans were looked at. There was no evidence of any achievable goals being set with the input of residents to maintain their independence. Nutritional assessments had not been undertaken potentially putting vulnerable residents at risk and not all information included in the plans care plans was up to date. Assessments of risks to residents had not been consistently undertaken, for example a resident who has a history of wandering and falling had not had these assessed and strategies for Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 11 minimising them had not been undertaken. The provider and care supervisor discussed plans to improve the format of care planning at the time of this visit. Residents said they were happy with the care given at the home. One care plan included a life history of the resident that had been written by a relative. No residents are currently looking after their own medication at Pinhay House. The manager said that if a resident wanted to do this they would be supported by staff at the home and a lockable space would be provided in their room for the safe storage of their medicines. Although residents are asked to sign a “disclaimer” when they accept the responsibility of this task no risk assessment is undertaken by staff at the home. For example, does the resident know why they are taking medication, do they know when to take it, are the fully aware of any consequences if it is not take, and any possible side effect, can they manage to open the containers and who is responsible for ordering repeat prescriptions. This was discussed with the care supervisor and provider who agreed that a risk assessment would be compiled. Not all members of staff who administer medication at the home have undertaken appropriate training. This puts residents at risk of receiving the wrong medication. During this visit the administration of medication was seen to be thorough and safe. A record of medication that had been hand written did not include the amount of medication received at the home and had been signed by only one person. A second person should check the accuracy of the recording to ensure that the information is correct. All residents spoken to confirmed that they are treated with dignity and that their privacy is respected by staff at all times. Staff were seen knocking on residents’ doors and waiting to be invited in before doing so. A telephone is provided on each floor at the home to enable residents to make, or receive, calls in comfort and privacy. At the time of this visit some residents’ privacy and dignity is being compromised by another resident. Residents’ rooms are being entered and daily reports include comments relating to these residents “being frightened”. The situation also puts the resident at risk. Residents generally have access to healthcare services that meet their needs including chiropody, opticians, dentists and district nurses. However, health care professional had not been consulted about the relatively sudden change in the needs of this resident. This was discussed at length with the provider and the care supervisor. Strategies for dealing with this were discussed. A GP was consulted at the time of the visit and care plans were being updated to include all information relating to care needs and risk assessments which were not previously detailed. Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 12 Both questionnaires received from residents said “ Staff are always considerate and helpful” and “Always available when needed” and three health care professionals stated that they were all satisfied with the overall care provided at the home. Pinhay House DS0000022010.V293204.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): OP 12, 13, 14 & 15. Quality in this outcome is good. This has been made using available evidence including a visit to the service. Social activities and meals are well managed, creative and provide daily variation and interest for people living at the home. Residents are encouraged to maintain their independence, exercising choice and taking control of their lives. EVIDENCE: The daily routine, including getting up and going to bed and mealtimes, appeared to be flexible. Staff said there were no actual routines at the home, residents were able to choose what they did and when. Residents’ interests, preferences and a record of activities that they have taken part in are included in care plans. The home employs an activities person who is responsible for planning a programme of activities and encourages and stimulates residents to take part. She visits residents who choose to stay in their rooms and spends time with them. during this visit residents were seen enjoying games, listening to music, some went into the garden and planted up some pots and some joined in a quiz. Two questionnaires were received from residents, both confirmed that activities were usually or sometimes arranged at the home that they could take part in. Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 14 All residents spoken to said they enjoyed the food served at the home. Residents are given the choice of being served their meals either in their rooms or in the comfortable dining room. The inspector was present when lunch was served; the meal was well presented and nutritious. Staff were seen supporting residents, needing assistance with eating, sensitively and discreetly. Comments made by residents included “food is always good” “if I don’t want what is on the menu I am always offered something else, but that doesn’t happen very often as the cook knows what I like and don’t like”. A choice of sweet is offered at lunch time but not of the main course; a choice is always available at the evening meal. The day’s menu is displayed on a board in the dining room. There is no restriction on visiting times and visitors to the home were greeted by staff in a kind, friendly manner. Residents may choose where they want to spend time with their visitors, either in the privacy of their rooms, the dining room or in the lounge. Pinhay House DS0000022010.V293204.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): OP 16 & 18. Quality in this outcome is adequate. This assessment has been made using available evidence including a visit to the service. Residents are confident that they are listened to and their requests carried out. Arrangements for protecting residents and responding to their concerns are satisfactory. Improvement in some staff knowledge of correct procedures for reporting issues of abuse is needed. EVIDENCE: Records of incidents recorded indicate that all issues are taken seriously and dealt with promptly. Residents confirmed that they feel comfortable discussing any concerns with staff at the home although some were unable to confirm that they had seen the home’s written policy. [A copy of the home’s complaint procedure is included in the service users’ guide, which is given to all residents before admission] No complaints have been made to either the home or the Commission since the last inspection. One resident’s questionnaire stated that they “always knows how to make a complaint” and another “always know who to speak to”. There was nothing to suggest that residents are anything other than well cared for at the home. Residents said that staff were very helpful, respectful and that nothing was ever too much trouble for them. Staff have undertaken Adult Protection training since the last inspection and were able to discuss different forms of abuse. They all said that they would not hesitate to report any suspicion of poor practice. One member of staff was unsure of the appropriate action to be taken if an incidence of alleged abuse were reported to her. She agreed that a refresher would be beneficial. Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 16 The implication of a resident being aggressive and “ frightening” other residents was discussed at length at the time of this inspection. [These issues have been highlighted in health and personal care and privacy and dignity]. Pinhay House DS0000022010.V293204.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): OP 19 & 26. Quality in this outcome is adequate. This has been made using available evidence including a visit to the service. Residents are provided with safe, comfortable surroundings. Some infection control practices require some attention EVIDENCE: The home is.generally well maintained, with comfortable accommodation provided for residents including a lounge and dining area. Residents’ rooms were homely and many had been personalised with their own belongings and some small items of furniture; all were well decorated and fresh. The home is clean and pleasant. Hand washing facilities are provided in all residents’ rooms and bathrooms. Staff were not following acceptable infection control procedures during this visit. A carer took washing outside to the laundry. No protective clothing such as gloves or aprons were used. Although hand-washing facilities in the form of water and towels were provided in the laundry no soap was available. This puts residents at risk of infection. The Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 18 laundry is situated outside of the main building and the floors and walls are not easily cleanable. At the time of this visit the laundry was not clean. A strip of carpet in the laundry was worn and damp, there were tissues and debris on the floor and cobwebs on the walls. Two residents’ questionnaires stated “the home is always fresh and clean”. Pinhay House DS0000022010.V293204.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): OP 27, 28, 29 & 30. Quality in this outcome is good. This has been made using available evidence including a visit to the service. The number of staff on duty throughout the day and night meets residents’ health needs. Residents are protected by the homes robust recruitment procedure. EVIDENCE: Residents said they were satisfied with the care they receive and that their needs are generally met. The number of staff on duty on the day of the inspection was sufficient to meet current residents’ needs during the day. The manager aims to have 3 carers on duty between 7.30am-8.am, 4 between 8.00am-2pm, 3 carers between 3.30am-9.30pm and 2 carer between 9pm-7.30am. The home employs a cook from 9am –3pm daily. When feasible the evening meal is prepared by the cook during the morning so that care staff have to only serve the meal. The manager is also generally available at the home between 9am-5pm.The manager is currently only working 2-3 days a week. Mr. Robin Hodges, provider, and a care supervisor are covering duties at the home when she is not available. Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 20 Training provided at the home has been limited since the last inspection. According to information included in a pre inspection questionnaire, during the last 12 months staff have received updates in oral health for the elderly, health and well being in older people, dementia care, first aid, managing challenging /aggressive behaviour and basic food hygiene. In addition staff have undertaken mandatory training, which has included fire safety and manual handling training. However, not all staff have received all training. Not all staff who administer medications have received safe handling of medicines training, not all staff who handle food have received basic food hygiene training and not all staff have received a period of induction when starting employment at the home. Only 17 of care staff hold an NVQ level at level 2 or above. This was discussed with the provider and the care supervisor who explained that due to staff illness training had not been pursued as diligently as usual. The home plans to make staff training a priority for improvement. Staff spoke about areas of training which they feel they and residents would benefit from. This includes updating first aid, dementia care, infection control and basic food hygiene knowledge. Three staff files were looked at and all care staff had been recruited using robust procedures to ensure the protection of residents. This includes obtaining Criminal Record Bureau (CRB) checks, two written references and a completed application form. A staff questionnaire returned stated that “it would improve staff communication at the home by having staff meetings” another “find it very frustrating that the home has to train staff, especially to NVQ level when as soon as this is done they up and leave”. Pinhay House DS0000022010.V293204.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): Op 31, 33, 35 & 38. Quality in this outcome is adequate. This has been made using available evidence including a visit to the service. Quality assurance is not managed efficiently. Systems are in place to ensure that residents’ personal monies are correctly managed. Satisfactory systems are in place to promote the safety and health of residents and staff. EVIDENCE: The home does not currently have an established quality assurance system to ensure that residents will benefit from influencing the way the home is run. The provider and staff said that throughout daily contact with all residents their wishes and comments were noted and acted upon. The provider spoke of Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 22 improving the format of a previously used questionnaire, which they are preparing to repeat. Currently resident meetings are not held but this is something that would be considered in the future. The home plans to undertake a quality assurance survey soon. The owners are always pleased to speak with residents and family. The inspector looked at the personal accounts of two residents. Each is kept securely in a locked space. Each account is kept separately and records and receipts are kept. Balances were checked and were found to be in order. Fire safety equipment, for example fire extinguishers, had been regularly serviced and the fire log showed regular checks and maintenance on emergency lighting and fire alarm. The pre-inspection questionnaire demonstrated that mandatory training, moving and handling and fire prevention training, is well managed at the home. Four members of staff hold a first aid certificate, which is due to be updated. Infection control procedures at the home are at risk of being compromised thereby putting residents at risk. [See OP 26] The home does not currently have a satisfactory induction and foundation training and updates. [See OP 30] An area of the roof has leaked recently. This is being attended to. A large hole in a ceiling has been created in order to dry the roof space. This does not present any immediate hazard to residents but the progress of the repair was discussed with the provider. It is planned that the repairs will be completed before the end of August 2006. Pinhay House DS0000022010.V293204.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 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 1 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15[1] Requirement Timescale for action Unless it is impracticable to carry out such a consultation, the registered person shall after consultation with the service user, or representative of his prepare a written plan as to how the service users’ needs in 27/07/06 respect of his health and welfare are to be met, and (b) keep the service users plan under review. The registered person shall ensure that any activities in which service users participate are so far as practicable free from avoidable risks. [This relates to comprehensive risk assessments not being consistently undertaken for residents] 2. OP7 13[4][b] 27/08/06 Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 25 3 OP8 13[b] 4 OP9 13[2] 5 OP10 12[4] 6 OP26 13[3] The registered person shall make arrangements for service users to receive where necessary, treatment and other services from any health care professional. [This relates to a resident whose needs have changed and no health care professional had been consulted] The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. [This relates to providing training for all staff who administer medication] The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. [This relates to residents’ privacy and dignity being compromised by a situation which has arisen at the home] The registered person shall make suitable arrangements to prevent infection and the spread of infection at the home. [This relates to staff not complying with the infection control procedures at the home, no soap being available in the laundry and inadequate cleanliness in the laundry room] 28/07/06 27/08/06 27/07/06 27/08/06 Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 26 7. OP33 24(1) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. [This refers to the lack of consistency in the home’s approach] This is the second time this requirement has been made. 31/07/06 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 OP3 Good Practice Recommendations The information included in pre admission assessments should be consistent and in sufficient detail to ensure that the home is able to meet peoples health and social care needs. Residents who choose to look after their own medication do so within a risk assessment framework. Two members of staff should sign to confirm hand written information on medication records are correct Procedures for reporting allegations of suspected abuse or neglect should be understood by all staff. 2 3 4 OP9 OP9 OP18 Pinhay House DS0000022010.V293204.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Pinhay House DS0000022010.V293204.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!