Inspection on 12/03/07 for Plane Tree Court Care Village

This inspection was carried out on 12th March 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Plane Tree Court Care Village 04/11/09

Plane Tree Court Care Village 01/07/08

Plane Tree Court Care Village 17/08/07

Plane Tree Court Care Village 25/04/06

Plane Tree Court Care Village 15/11/05

Plane Tree Court Care Village 14/06/05

Plane Tree Court Care Village 16/12/04

Plane Tree Court Care Village 13/07/04

Plane Tree Court Care Village 19/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ross House 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX Lead Inspector Kath Oldham Unannounced Inspection 12 March 2007 09:00 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 Ross House DS0000008587.V315512.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. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ross House Address 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX 0161 480 6919 0161 286 3175 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) Altruistic Care Limited Care Home 44 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (5), Old age, of places not falling within any other category (44) Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 44 OP and up to 5 MD (E). Date of last inspection 25th April 2006 Brief Description of the Service: Ross House is a large, detached building set in its own grounds in Edgeley, a suburb of Stockport. There are local amenities situated close by. Altruistic Care Limited owns the care home. The directors of the company are Mr and Mrs Jivraj. The owners visit the care home on a regular basis and Mr Ken Thomas carries out the Regulation 26 visits on behalf of the registered person as defined within the Care Home Regulations 2001. The care home is on four floors, with a passenger lift to assist service users to mobilise to the upper floors. Lounge and dining areas are situated on the ground floor with an additional lounge on the first floor. The home is undergoing a massive refurbishment and having an extension built. The home currently accommodates a maximum of twenty-eight service users to ensure they are not inconvenienced by the building work. The home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. The fees for staying at the home were reported to be between £315 and £500 per week. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of the key inspection, which included an unannounced visit to the home on 12th March 2007, commencing at 9:00am. The purpose of the inspection was to monitor the care and service provided at the home, to check that it was of a good standard and to ensure compliance with the regulations. Time was spent in conversation with the manager and talking with service users to get their views and experiences of living in a residential care home. People visiting the home were also spoken with. The inspector undertook a tour of the building and looked at a selection of service user and staff records, as well as other documentation, including staff rotas, medication records and some maintenance documentation. A meal was taken with service users. Ross House was inspected on 25th April 2006 when all the key standards that must be inspected each year were assessed. There were 20 requirements issued on that inspection, in addition to six good practice recommendations. A further site visit was undertaken on 9th August 2006, where the focus was to monitor the developments of the care planning process and the routines for the administration of medication. The visit was also used to inspect the premises. An additional four requirements were issued on that visit which related to service users’ medication and care planning. Staff contributed to the inspection through their conversations with the inspector, in addition to completing comment cards. Twelve comment cards were left at the home for completion by service users, some who would need assistance from their friends, relatives or staff. Additional comment cards were left at the home for distribution to service users’ friends and relatives, to get their feelings and opinions about the care and the support their cared for service user receives; comments received are included within this report. Verbal feedback was provided to the acting manager during and at the end of the site visit. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The majority of the requirements issued on previous inspections have been fully complied with or are to be addressed in the refurbishment of the house. It was reported that all service users or their families or representatives have received a copy of the service user guide, which goes some way to informing them of the service the home provides. Service users are being assessed before they are accommodated at the home to ensure the home’s staff have the skills and abilities to meet the needs of service users. This has been an outstanding requirement for almost two years, which has now been addressed. The appointment of the manager in February 2006 has had an effect on the quality of care and support service users receive. Staff training has been arranged and the manager has ensured through direction and supervision that the training is transferred into practice. There have been few staff appointments and fewer service users, which was needed to ensure that the quality of care was the focus of staff intentions. Great improvements had been made to the administration of medication to service users. The practice and routines to ensure that these safeguards are in place need to continue to ensure compliance. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 7 The interactions between staff and service users were, in the main, much improved and staff appeared more aware of the needs of service users, which were encouraged and promoted. Service users are routinely engaged in activity or stimulation. Service users said this made them feel better in themselves and gave them a focus to the day. One service user said it was so busy that the days flew by. Service users’ abilities and skills appear now to be known by staff and they were seen talking and supporting service users to carry out tasks. 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. The summary of this inspection report can be made available in other formats on request. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 (Standard 6 is not applicable) Quality in this outcome area is good. Prospective service users receive a full assessment that assures them their needs will be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A service user guide was available. The acting manager said that all service users or their families have been given a copy of the service user guide and are asked to read it. The requirement to give all current and prospective service users a copy of the service user guide has been met. The acting manager undertakes an assessment of the service user in their own home or on the hospital ward if they are going into care from there. An assessment is recorded by the home. For service users who are being funded by the local authority, social or health care workers undertake an assessment. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 10 The acting manager said that part of the assessment includes looking at the skill mix of staff and the abilities and needs of the current service user group to ensure the home can meets service users’ needs. The requirement to ensure that service users admitted to the home do not adversely impact on those already resident has been addressed by the home by the changes made to the assessment of service users. Examination of a sample of service users’ files found that an assessment was available in all files inspected. Ross House does not offer intermediate care. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Quality in this outcome area is good. care, which are regularly reviewed to they have access to medical services This judgement has been made using this service. Service users have individual plans of ensure they reflect current needs and to ensure their health needs are met. available evidence, including a visit to EVIDENCE: A selection of service users’ files was looked at. All had a written copy of a care plan. The written care plans are presented as containing sufficient detail to enable staff to offer appropriate care. There was also documentary evidence that care plans were regularly reviewed. In the files seen there was evidence that the home had sought a ‘social history’ of each service user. This level of information in connection with each person assisted staff to relate to people as individuals. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 12 Service users are weighed monthly and an indication is made whether there is any weight gain or loss and what action is taken as a consequence. More frequent weights would be taken if it were identified that there might be a problem. Examination of the records completed by staff each day and night to detail the care and support service users receive identified appropriate completion. A separate record is kept to detail when service users have a bath. The language used in this record detailed staff’s perceptions of how services users felt when they had a bath. Staff need to be reminded, and need to receive additional direction in, what should be contained within these records. Examination of service users’ records identified appointments chiropodists, district nurses and other health care professionals. with Observations of care practice identified that the support and interventions of staff didn’t always promote service users’ privacy and dignity. For example, one member of staff took it upon themselves to select individual biscuits for service users, as opposed to them choosing a biscuit for themselves. Observation of care practice and routines identified some unsafe moving and handling techniques used with service users. The practice undertaken by staff, including a senior staff member, did not promote the safety or respect of the service user. The manager said that moving and handling training was scheduled to take place on the days after the inspection. Other interactions with service users were respectful and promoted their individuality, respect and wellbeing. It was reported that no service users had pressure sores. Examination of the medication administration records identified that, in the main, they were all signed. There were a couple of omissions in the recording but were much improved on those seen previously. When medication was not administered, for whatever reason, this was recorded. Handwritten medication records were held and not signed by two members of staff. When a variable dose was prescribed, this was indicated in the record so an accurate record of exactly what medication is administered to service users is maintained. Photographs were on file as a means of identification, which is best practice. All staff have received distance learning medication training. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 13 Examination of the controlled drugs record identified this to be completed in line with regulations. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 &15 Quality in this outcome area is adequate. Service users were satisfied with their lifestyles and are able to make their own decisions and choices, but meal presentation should be improved. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: An activities programme has been introduced at the home that provides service users with the opportunity to have some focus to their day. Exercises and throwing balls were some of the activities service users were taking part in. Some service users were singing along to the music and one service user took the opportunity of the music to dance. The home has an activities co-ordinator three times each week, in addition to staff taking the lead in organising short activities. One service user said they had recently planted bulbs in pots which, they were hoping, would grow in the spring. Photographs of events were shown to the inspector as a memory of past events. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 15 Service users also commented that they go out on trips organised by the home. Service users were able to receive visitors at any reasonable time. At least six staff are to attend a course on providing activities for people with dementia which will enhance the stimulation of service users who have dementia. The serving of meals has improved, in that, service users are provided with crockery as opposed to plastic plates as seen on previous inspections. Clean tablecloths and flower arrangements were on the tables. A four-week menu is in place that details the meals to be served each day. There was no alternative to the main meal indicated on the menu. The manager showed the inspector a variation to the menu, which she said was to be put in place clearly indicating an alternative to the main meal. The meal served on the inspection was described as minted lamb. The meal served was chopped meat, which was described as lamb, with mixed vegetables, green beans and croquette potatoes. The meal was warm. Some service users chose to have a salmon salad for lunch. Staff were observed asking service users what they wanted to eat for lunch and their preferences were provided. An individual record is maintained of the food served to service users so that a judgement can be made whether the diet is satisfactory in terms of nutrition. However, it was not clear whether action was taken when service users did not eat their meals. A board in the dining room details the meal to be served, which provides service users and staff with the opportunity to check what the meal is. One service user said the meals were “beautiful”. Senior staff and cooking staff have undertaken recent updates to food hygiene training and, as part of their development, the cooks are to attend another of the registered person’s homes for further cooks’ training. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Procedures for dealing with complaints were in place, however the recording needs to be improved. Service users are protected from abuse or exploitation by the home’s policies and practices. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of the complaints record identified two entries, both from service users, one was not a complaint. The second entry gave a clear indication of the problem, the action taken and the outcome. The manager said she had once again spoken with staff to encourage them to record comments and complaints received. There needs to be further work undertaken to promote the use of the complaints record. Service users indicated that they were aware of who to complain to and had not had reason to complain. The Commission for Social Care Inspection has not received a complaint since the last inspection. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 17 The home has a policy and procedure to respond to allegations of abuse. The policy has not been updated to reflect best practice, changes in legislation and needs to include reference to the local authority’s protection of vulnerable adults procedure. It was reported that all staff had received training in issues relating to the protection of vulnerable adults. This has provided staff with the skills and knowledge to identify signs of abuse and be aware of what actions that must be taken if abuse is alleged. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 Quality in this outcome area is good. The work undertaken in the refurbishment and the plans to improve the remaining facilities in the home promotes the respect and dignity and recognition of service users as individuals. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: In the months since the last site visit, the refurbishment of the first floor has continued and is near completion. It was reported that the first floor should be completed by the end of April 2007. The quality of the finish is excellent with great attention paid to the standard of fixtures and fittings. It is understood that the remainder of the house is to be refurbished to this quality. New bedrooms have en-suite toilets and shower rooms, and will provide service users with space to access these rooms independently and with ease. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 19 The bedrooms were large and, although not measured, appeared to be in excess of the standard size. Service users, if they so chose, could use these rooms as bed sitting rooms and have space for lounge seating. The corridors are wide which will enable service users to move round the home independently. The laundry is to move to another area of the home in the planned refurbishment. Advice has been given previously to ensure the size of the laundry is suitable to cater for the planned increase in service users. There continues to be a strong odour of urinary incontinence at the home. Despite staff’s efforts in cleaning and improvements in care practice the odour is still apparent. Although not as strong as on past inspections, an odour is still present. It is hoped that the refurbishment of the home and the deep cleaning or removal of fixtures and fittings will improve urinary odours in the house. The registered person has stated previously that he felt the positioning of the toilets on the ground floor has an impact on the odour in the house. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. The absence of a thorough recruitments and selection procedure and induction training compromises the safety of service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of the two most recently appointed staff files identified some improvements to the records which must be kept and the checks that should be undertaken as a safeguard to service users and staff at the home. The information contained within the two files examined, although improved upon, was not to the required standard. One member of staff had not had a Criminal Record Bureau check processed and had commenced work without this. In addition, only one reference was on file for the staff member. The manager said that she had contacted the referee on three separate occasions and that a verbal reference had been received. There was no evidence to substantiate this. The second staff file examined identified that a Criminal Record Bureau check had been requested but not received back. A POVA first check had not been requested or received, as is desired practice when starting new staff without a criminal record disclosure. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 21 There was no evidence of staff having had induction training to Care Skills specification. The manager said that the home had researched the induction and foundation package from Skills for Care and would pursue this request for information. Staff have meetings with management when they have the opportunity to influence the running of the home and contribute to its developments. Eleven staff have benefited from the attendance to first aid training, 12 staff have undertaken COSHH training. Housekeeping staff are undertaking infection control training to improve their awareness on this subject. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 36 & 38 Quality in this outcome area is adequate. The appointment of the manager has significantly improved the standard of care to service users and the morale of the staff group. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The manager was appointed to her role in February 2006 and has NVQ level 4 in management and care and has obtained the Registered Manager’s Award. An application to propose the manager for consideration for registration as manager has not taken place. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 23 It was apparent on the site visit that the manager’s implementation of care practice and the attention to detail she places on service users receiving the care and support they should have has been transferred into practice by staff. Staff were observed to be more confident in their roles and interacted with service users. There continue to be some areas of development needed and some staff need additional direction and supervision, which the manager is aware of. The manager has worked hard to address in some cases the long-standing requirements. The manager said that she spends time on the floor supporting and assisting staff in their role. Staff supervision is in place and areas of development have been identified and implemented to further improve the quality of care to service users. A selection of records relating to money held on behalf of service users were looked at. These records presented as being appropriately maintained with receipts in place for items purchased on behalf of service users. Health and safety procedures presented as being effectively implemented. A small selection of records relating to the maintenance of equipment and the fire detection systems was looked at. These presented as being appropriately maintained. Staff confirmed they were provided with protective equipment, including disposable gloves and aprons, to minimise the risk of cross-infection. All staff were reported to have taken part in fire drills and practices to make sure staff know what to do in an emergency. Examination of the fire safety records identified routine fire drills and practices having taken place. The home maintained up to date records on the checks undertaken to the fire alarm test and means of escape, in line with fire authority regulations. A record was not available to confirm checks have been made to the emergency lighting at the frequency determined by the fire authority. There were some areas of the home where the fire protection system was compromised. The home recorded information in respect of falls and accidents by service users. How the home is maintaining these records does not comply with Data Protection legislation. The maintenance of all appliances and equipment is carried out under contract. Those seen were carried out as required by health and safety legislation. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 24 A representative of the registered person visits the home monthly, in line with the regulations, to ensure that they are aware of how the home is operating. The visit includes seeking the views of service users, staff and relatives or visitors; the building is also inspected as part of this visit and checks are made on specific records. Copies of these visits are held at the home. The CSCI has been notified of events in the home, which affect the health, safety and wellbeing of service users. The acting manager confirmed her awareness of matters, which need to be notified in line with regulations. The requirement to undertake this has been complied with. Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 X 3 X 1 Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 18(1) 23(2) Requirement The registered person must ensure that the home is odour free. (Timescales of 28/02/05, 31/08/05, 31/01/06 and 08/08/06 not met). The registered person must, taking reference from Skills for Care induction and foundation training, provide staff with induction and foundation training within six months of appointment and record this. (Previous timescales not met). The registered person must ensure that enhanced Criminal Record Bureau disclosures are obtained for all care staff employed at the home and staff do not commence work until all checks, including references and CRB disclosures have been obtained. (Timescale of 08/08/06 not met). The registered person must propose to the CSCI a manager for consideration for registration. Timescale for action 31/05/07 2 OP30 18 30/04/07 3 OP30 19 12/03/07 4 OP31 8,9,10 30/04/07 Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 27 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. 5 Standard OP26 Regulation 13 Requirement The registered person must ensure that a policy and procedure for the prevention of infection is written and implemented within the home. (Timescales of 20/10/05 and 08/08/06 not met). Timescale for action 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP15 Good Practice Recommendations The registered person should ensure that when handwriting medication, the entry is also signed by a second staff member to verify that the entries are correct. The registered person should review and amend the preparation, presentation and quality of food, ensuring service users are not compromised by the lack of imagination and attention to detail. The registered person should develop the recording in the complaints book ensuring that staff complete the record and are aware of what constitutes a complaint. Record the action taken. 3 OP16 Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 4 Refer to Standard OP18 Good Practice Recommendations The registered person should research the content of the local authority’s protection of vulnerable adults procedures, ensuring they are compatible with the homes policy and procedural guidelines. The registered person should continue with the programme of redecoration and refurbishment. Service users and/or their families/representatives should be given the opportunity to choose the furnishings. The registered person should ensure that the accident records are kept in line with Data Protection legislation. The registered person should ensure that the kitchen cleaning schedule records are completed at the regularity of environmental health guidelines. The registered person should ensure all checks to fire safety, including checks to the emergency lighting, are undertaken at the frequency determined by the fire authority. The registered person must cease the practice of wedging doors open. 5 OP24 6 7 8 OP38 OP38 OP38 9 OP38 Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ross House DS0000008587.V315512.R01.S.doc Version 5.2 Page 30 - 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!