Inspection on 15/11/05 for Plane Tree Court Care Village

This inspection was carried out on 15th November 2005.

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 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 12/03/07

Plane Tree Court Care Village 25/04/06

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 OTX Lead Inspector Kath Oldham Unannounced Inspection 15th November 2005 08:15 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.V263692.R01.S.doc Version 5.0 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.V263692.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ross House Address 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 OTX 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.V263692.R01.S.doc Version 5.0 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 14th June 2005 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 with Mrs Jivraj carrying out the Regulation 26 visits 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. Ross House accommodates service users in 30 single and seven double bedrooms. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and commenced shortly after 8:00am on 15th November 2005. The inspection was undertaken to monitor compliance with the regulations and standards. Time was spent observing staff practice and routine, examining records and speaking with service users. A partial inspection of the premises was undertaken. Comment cards were left at the home to distribute to service users and their visitors. Comments from service users are included in the report. What the service does well: What has improved since the last inspection? Since the departure of the registered manager two managers have been appointed who have only stayed for a short time. This has had an impact on the level of care provided to service users. In the short term, a manager from another home is spending time at Ross House in an attempt to develop the service and the quality of care provided to service users. Developments have been made with the involvement of the manager, however this will not be sustained at the home without ongoing development and guidance to staff. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 6 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. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 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 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 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): 3 A detailed assessment of service users prior to admission is not undertaken. EVIDENCE: There was no record of the different treatments or care management for people with mental health needs. The records did not show that ongoing assessments for people with changing mental health needs were undertaken. There were service users in the home with dementia and other mental health problems but it was not apparent from observation of staff practice that staff were aware of the different care strategies that may be necessary to meet these needs. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 9 It was not apparent that health care professionals were requested to attend to service users to assess or meet their changing health care needs. One service user was being cared for in their room. The door was open and she was seated in a lounge chair sleeping, with no support to promote her comfort. The care files did not detail the care interventions or the support they were receiving. A service user whose health care needs had deteriorated was being looked after in her bedroom on the upper floor, in the chair. She was isolated from company; there was no television or radio for her use in the bedroom. The service user needed the assistance of two staff to move her and had recently been provided with pressure relieving equipment which wasn’t in use. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Care plans and risk assessments failed to record all care needs. was not administered correctly. Medication EVIDENCE: Examination of care files identified that care plans were in place. The detail in the care plan was, in some cases, minimal and on other occasions was not reflective of the care needs of service users or what was being provided to them. Staff said they had not been included in the compilation of the care plans and they had been undertaken by the previous acting manager in isolation. The daily and night reports, when completed, contained information about how service users had spent their day. They must be completed daily to demonstrate the care and interventions provided. Routines and care support were not always recorded. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 11 District nursing staff visit the home to attend to service users’ health care needs. The recent introduction of a communication book should assist in improving communication about service users’ care needs. Health professionals had contacted the CSCI to express their concerns with regard to vulnerable service users being left in bed due to the lack of staff and poor deployment of those on duty. Doctors attend the home when requested. A record was not easily available to confirm the doctors or other visiting health care professionals to specific service users. Senior staff said there had been no changes in the administration, storing or recording of medication administration. The senior staff member responsible for the administration of medicines was observed to handle medication and to leave the medication trolley unattended to answer the front door. Observation of staff practice and routines did not confirm that service users’ continence was promoted. The home continues to have an odour of urinary incontinence and a number of service users have a malodour about their person. Some staff did spend time discussing and attempting to evaluate the needs of service users. Some staff approaches were consistent with good practice. These skills should be further developed through training, direction and supervision. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Limited choice and poor provision of meals has the potential for service users to receive inadequate diet. EVIDENCE: One service user said they had been awake since 6.00am and had not had a hot drink. A further service user said they didn’t function until they had their first cup of tea. Neither received a drink for some time after coming downstairs. Service users are routinely sat at the table when they come down in the morning, waiting for breakfast. Some service users with dementia or mental health needs were unaware of what was expected of them whilst sat at the table waiting. The mealtime shared with service users appeared to be task oriented with service users eating their food then leaving the room. No efforts were made for the mealtime to be an enjoyable experience. Time was not taken by staff in either the preparation of the tables with clean tablecloths or in discussion about the meal. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 13 Thought didn’t appear to be taken about seating arrangements of service users at mealtimes, with specific service users sitting alone at a table and having to get up to ask others for condiments. Service users were not asked individually whether they wanted any additional helpings. The cook interpreted the lack of response from service users to mean they didn’t want any more food. Liquidised diets were poorly presented with no identification of different components of the meal. A record of food served is no longer maintained at the home in sufficient detail to determine whether the diet taken is nutritious. An alternative method has been introduced at the home due to the lack of records being kept accurately in the past. This record is not sufficient in its detail. The menu was not a reflection of the meals to be provided at the home. The cook said she hadn’t always the food in to cook the planned menu. The manager seconded to the home indicated that a revised menu was in place and that the ordering of food was to be reorganised. An activities co-ordinator has been appointed to the home and is employed three mornings each week. The deployment of the hours in the morning is to be evaluated. A separate activities record is maintained which included watching videos, playing games, arts and crafts and music and exercise for some service users. Other service users continue to be without stimulation or activity. The daily reports do not include what effect the activity had on their day. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Procedures for dealing with complaints were in place, however the recording needs to be improved. Staff were not aware of adult protection strategies. EVIDENCE: The complaints record could not be located. Senior staff said that if a service user or their representative made complaints about the service, they would contact management. Previously, the examination of the complaints record identified that there were no comments or complaints about the service. A number of the staff have attended training in what constitutes abuse and the actions to be taken to safeguard service users. Records in relation to training were not contained within a number of staff files examined. An overall picture of how many staff had undertaken this training could not be confirmed. It was confirmed that newly appointed staff had not received training in adult protection. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 The lack of repair, replacement and upkeep of the home does not promote the safety, security, comfort and respect of service users. EVIDENCE: As reported on previous inspections, there was an unpleasant odour in the hall, lounges and dining rooms, and although domestics were employed, the routines did not appear to keep the home clean and odour free. The commission has met with the registered person in relation to this matter and have been informed that a major refurbishment is to take place of the home to improve the environment. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 16 The environment has not changed since the inspection undertaken in June 2005. The record of the observations made on that inspection are reproduced in their entirety from the last inspection report. Additional concerns regarding the extent of windows open in some service users’ bedrooms and the fact that a number of fire doors did not close sufficiently into the rebate are issues which are of some concern and are identified as needing immediate attention. Service users complained that the picture on the television was not clear, so they couldn’t enjoy the programme. The television stayed on the same channel during the inspection. Service users did not appear to have a remote control to change channels. A number of toilet areas were without heating, the rooms presented as very cold and unwelcoming. A number of the toilet doors did not indicate what the room was. The bathrooms had old or unused frames, wheelchairs and blankets stored in and around the bath, which minimises their use and compromises the health and safety of service users and staff. The bathrooms also contained prescribed creams and lotion which, if used for other service users, could result in cross infection. Carpets in the hallways were ill fitting. A number of the bedrooms had been redecorated and had replacement carpet. The remaining bedrooms were in need of redecoration and new carpeting. A number of bedrooms did not have numbers on the doors; some service users would have difficulty in finding their bedroom on their own. In an emergency, bedrooms may not be located quickly, which may potentially put service users at increased risk. One wall of a bedroom was black with damp, the adjoining bathroom walls had plaster showing. It was reported that this room continues to be out of commission. Fluorescent lighting remains in place in parts of the building. Such lighting is unsuitable for constant use in areas used by service users. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The lack of skills and staff training, supervision and direction compromises the level of care and support provided to service users. EVIDENCE: The majority of the night staff team are newly appointed. Examination of staff files did not evidence that they had received any training. The night staff personnel files identified that a senior carer did not have experience within a care home or receipt of basic care training. Comments indicated that at night service users were experiencing some communication difficulties with the staff on duty and their manner and approach was not what they were used to. Examination of the staff duty roster identified that when all staff are on duty there are five staff until 2.00pm, with four staff in the afternoon. On the inspection four staff were on duty up until 8.00pm, with three staff on duty during the night. Additional staff are needed to meet the needs of service users. There are 70 hours allocated to domestic duties at the home each week. The duty roster indicated that staff work up to 2.00pm each day, after which time no domestic duties are undertaken. Laundry, kitchen and cooking staff are employed at the home. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 18 Staff were observed arriving for work after the commencement of their shift which means that staff need to stay while awaiting their arrival. It was reported that this happens routinely. A number of staff have obtained NVQ level 2 qualifications with one of the senior team having NVQ level 3. A number of staff said they were interested in obtaining NVQ level 3 but, due to the cost, they were unable to afford to do so. A record was not available to evidence the training staff have received. Examination of a sample of new staff files identified that there was no record of them attending any induction training, which must be in place when working in a care home. Some of the new staff are working with colleagues who have also not had any training. Further examination of staff files identified that all the records and checks that must be in place were not. Previous inspections have identified the recruitment and selection to be lacking, which has the potential to put service users at increased risk. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 There is no manager and the home lacks leadership and direction. EVIDENCE: The lack of a manager has impacted on the care and support provided to service users. Staff do not have a clear picture of the needs of service users and their health care. Records were not always available due to staff not knowing where they were. This practice does not demonstrate that a holistic approach is in place to the benefit of service users. The manager from another home is providing some support to assist in the improvements and the development of care to service users. However due to other commitments, this is not full time and the routines that are being introduced cannot be reiterated and measured without continual supervision and direction. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 20 Advertisements have been made to recruit a suitable person for the management of the home and interviews have been scheduled. Examination of the accident records identified a large number of accidents, incidents and occurrences experienced by service users. An analysis of accidents may identify any patterns; this had not been undertaken. Risk assessments were not always in place for service users who were at risk of falling and were not amended to reflect changes in routines and practices as a consequence to falls or accidents. This should be in place to safeguard service users. Records have been recently introduced to detail the cleaning of the kitchen. An environmental health inspection earlier in the year identified that a thorough cleansing of the kitchen was required to comply with standards. The lack of cleanliness of the kitchen was reported to have been recently discussed with the cook in charge and will continue to be monitored by the home. The cook was reported to have attended food hygiene training. Cooking staff need to ensure the training they have attended in relation to food hygiene is put into practice. Examination of the fire safety records identified that fire safety checks had been undertaken regularly. Examination of the record of fire drill training identified that not all staff had taken part. In particular, night staff had not received this training, which could put service users and staff at risk in an emergency situation. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation 5 Requirement The registered person must give all current and prospective service users a copy of the service user guide. The completed service user guide must be forwarded to CSCI. (Timescales of 30/09/04, 28/02/05 and 31/08/05 not met). The registered person must obtain a full assessment prior to the admission of a service user to the home. (Timescales of 28/02/05 and 31/08/05 not met). The registered manager must ensure that service users admitted to the home do not adversely impact on those already resident. (Timescales of 28/02/05 and 31/08/05 not met). Timescale for action 31/12/05 2 OP3 14 15/11/05 3 OP3 14 31/12/05 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 23 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. 4 Standard OP3 Regulation 14(1) Requirement Timescale for action 15/11/05 5 OP4 18(1)(c) 6 OP7 15 7 OP9 13 The registered manager must arrange for service users to be regularly reviewed and reassessed by practioners as their health and social care needs change. The registered person must ensure that service users at the home are within the home’s registration categories. The registered person must 31/01/06 provide staff, individually and collectively, with training to enable them to care for service users with mental health and physical care needs. (Timescales of 28/02/05 and 30/08/05 not met). The registered person must 31/01/06 ensure that the care plan details all assessed needs of service users, including the activity, occupation and stimulation which must be provided at the identified time. (Timescale of 31/08/05 not met). The registered person must 15/11/05 ensure that medication is administered to service users appropriately and that it is not handled when given out. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 24 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. 8 Standard OP10 Regulation 12(4)(a) Requirement The registered person must further promote the dignity and respect of service users by staff taking time and thought when assisting service users in their personal appearance. (Timescales of 31/08/05 and 05/10/05 not met). The registered person must train and direct staff in hygiene practices ensuring safe working practices are maintained and cleanliness is promoted. (Timescale of 31/08/05 not met). The registered person must, in consultation with service users and their representatives or visitors, provide occupation, activity and stimulation. The registered person must ensure that the record of food served is maintained accurately. (Timescale of 31/08/05 not met). The registered person must review and amend the routine at mealtimes to ensure that they are organised and put service users at the forefront of the meal. (Timescale of 31/08/05 not met). Timescale for action 31/12/05 9 OP10 12, 13 31/01/06 10 OP12 12(2)(3) 31/01/06 11 OP15 Sch 4(13) 31/01/06 12 OP15 16 31/01/06 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 25 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. 13 Standard OP16 Regulation 22 Requirement The registered person must 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. (Timescale of 31/08/05 not met). The registered person must arrange for all staff to attend training in what constitutes abuse. The registered person must remove prescribed creams and lotions from communal bathrooms. (Timescale of 31/07/05 not met). The registered person must ensure that the home is clean and odour free. (Timescales of 28/02/05 and 31/08/05 not met). The registered person must ensure that any areas of damp in the home are investigated and rectified. The registered person must ensure that bedrooms are not used as storage areas for equipment not in use. (Timescale of 05/10/05 not met). Timescale for action 31/01/06 14 OP18 13(6) 31/01/06 15 OP19 13(2)(4) 31/12/05 16 OP19 18(1) 23(2) 31/01/06 17 OP19 23 30/11/05 18 OP22 23 30/11/05 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 26 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. 19 Standard OP25 Regulation 13(4) Requirement The registered person must make safe the windows within specific bedrooms ensuring there are restrictors on the windows. The registered person must ensure that all doors that are designated as fire doors close sufficiently into their rebate. The registered person must ensure that a policy and procedure for the prevention of infection is written and implemented within the home. The registered person must redecorate the walls and replace the flooring in the laundry. (Timescale of 31/08/05 not met). The registered person must increase the numbers of staff on duty to meet the needs of service users. The registered person must obtain for each member of staff a copy of their birth certificate, passport, documentary evidence of any relevant qualification, two written references and evidence that they are physically and mentally fit for the purpose of the work they are to perform. (Timescales of 30/09/04, 28/02/05 and 31/08/05 not met). DS0000008587.V263692.R01.S.doc Timescale for action 15/11/05 20 OP25 23(4) 30/11/05 21 OP26 13 20/10/05 22 OP26 16(2) 23(2) 31/01/06 23 OP27 18(1) 30/11/05 24 OP29 19 Sch 2 31/01/06 Ross House Version 5.0 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. 25 Standard OP30 Regulation 18 Requirement 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. (Timescales of 26/09/04, 28/02/05 and 31/08/05 not met). The registered person must arrange for service users to have regular meetings. (Timescales of 31/10/04, 31/03/05 and 31/08/05 not met). The registered person must undertake a written analysis of accidents experienced by service users identifying any patterns to the accidents and detailing how these can be minimised for the service user. The registered person must ensure that risk assessments include more detail, particularly in relation specific nature of the risk and factors, which had been taken into account in managing the risk. (Timescales of 30/09/04,28/02/05 and 31/08/05 not met). Timescale for action 30/11/05 26 OP33 12(2)(3) 24 31/01/06 27 OP38 13(4) 30/11/05 28 OP38 13(4)(b) (c) 30/11/05 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 28 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. 29 Standard OP38 Regulation 13(2) 13(5) Requirement Timescale for action 30/11/05 30 OP38 23 The registered person must ensure footrests are in position on wheelchairs when in use. The registered person must ensure that equipment used by service users is maintained to a good standard and is clean. (Timescales of 28/02/05 and 31/08/05 not met). The registered person must 15/11/05 ensure that all staff when next on duty undertake a fire drill and practice and these are undertaken at a minimum of twice yearly. Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 29 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 OP14 OP18 Good Practice Recommendations The registered person should, over a period of time and to coincide with the refurbishment of the home, introduce new bedroom door locks to all service users bedrooms. 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 upgrade the decoration in the bathrooms and toilets. 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 replace all fluorescent light fittings in areas used by service users with appropriately styled fittings, which are conducive to a homely environment. 3 4 OP21 OP24 5 OP25 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 30 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: 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 Ross House DS0000008587.V263692.R01.S.doc Version 5.0 Page 31 - 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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