CARE HOMES FOR OLDER PEOPLE
Ross House 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX Lead Inspector
Kath Oldham Announced Inspection 25th April 2006 07:40 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.V290314.R01.S.doc Version 5.1 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.V290314.R01.S.doc Version 5.1 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.V290314.R01.S.doc Version 5.1 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 15th November 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.V290314.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place on 25th April 2006 commencing at 7:40am and concluding at about 4:30pm. The inspector went back to the home the following day to look at some records, which could not be located on the first day. The acting manager was on duty during the site visit and contributed to the day. Comment cards were sent to professionals who visit the home, including doctors, district nurses and social workers, who had been involved in the placement of service users at the home. Time was spent on the site visit speaking with service users, observing staff practice and routines and undertaking a partial inspection of the premises. Staff contributed to the inspection through their conversations with the inspector. A sample of the records, which are maintained for the purpose of regulation, were also examined. Twelve comment cards were left at the home for completion by service users, some who would need assistance from their friends, relatives or staff. The names and addresses of relatives was supplied by the home and a sample were sent comment cards 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. The inspector had the opportunity to have meals with service users during the visit. The registered person was also on the premises and spent time in discussion with the inspector. Verbal feedback was provided to the acting manager during and at the end of the site visit. What the service does well:
The staff are working as a team and appear to have developed their skills and understanding of the service user group. Staff said they were happy and felt much better having a good manager who spent time with service users and was able to guide and direct them. The staff team has remained stable with no recent resignations. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 6 Service users were complimentary about the staff team and said they felt well cared for. The management team are aware of the work that needs to be undertaken to further improve the quality of care for service users. They have put in place routines and practices to develop the staff group and are auditing the training that staff have received and what is outstanding. Staff confidence needs to be developed and their skills further enhanced. A number of the requirements from previous inspections have been addressed in full; others are partially achieved and are repeated. What has improved since the last inspection?
A manager was appointed at the home in February 2006 and has, in a few short weeks, improved the outcomes for service users. Staff morale is much improved and the staff appear to be working well as a team being supported and directed by the manager in providing an improved quality of care for service users. There are still offensive odours in the home, which are not as pungent as on previous inspections. Domestic routines have been improved upon and staff appear aware of cleaning routines and standards. Approximately 17 of the bedrooms have been repainted and some have had new carpets fitted, new duvet covers and curtains. All the bathrooms are now operational and the aids within them are working, which means that service users have a choice of bathroom and are having baths when they require. Service users were well cared for, with attention paid to how they were dressed. Since the last inspection visit the lighting in the public areas of the home has improved. Improved cleaning routines have been instigated which have gone some way to eradicating the odours within the home. New weighing scales have been purchased which are of a design that enables all service users to be weighed. Service users are weighed monthly or more regularly if this is needed. A record is maintained of these weights. The home has appointed a handyman who carries out general maintenance. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 7 In addition, to the appointment of a manager, a quality assurance officer has been appointed who has undertaken an audit of the home and the routines and practices. This will assist in the development of the home. The most recent appointment to the company is that of an Operational Director whose primary role is at Ross House initially. Staff practice when giving out medication was much better than that observed on previous inspections. The records kept at the home have been improved upon and are more easily available. The manager said that specific records in relation to staff cannot be located and time needs to be spent collating information together to meet the regulations. The statement of purpose and service user guide have been improved and sent for printing. The service user guide and supporting documentation needs then to be given to all service users and any new service users so they can be informed about the home and the care and services that can be provided. What they could do better:
There continues to be a malodour within the home, which is proving to be very difficult to eradicate. The registered person has informed CSCI that a major refurbishment of the home is to be undertaken which will totally upgrade all areas and will include fixtures and fittings. An extension is to be built to the side of the home. This will provide improved facilities to service users, which are very much needed. Staff said they were looking forward to the planned work. The recording of medication administration continues to need improvement to safeguard service users and staff. Training needs to be undertaken and put into practice to increase staff’s awareness of the importance of the records to evidence that service users have had their medication as it has been prescribed by there doctor. Criminal Record Bureau checks for staff who have been employed at the home for some years need to be obtained. Staff said they have completed the necessary paperwork for previous managers, however the disclosure has not been returned. One newly appointed staff member had the standard check undertaken instead of the enhanced check, which needs to be rectified. The remaining staff files need to be checked to make sure this mistake has not been repeated. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 8 Meals and mealtimes need to be given some attention to improve the presentation of meals and to promote service users’ enjoyment by improving the atmosphere in the dining room and the attention to detail when setting tables and serving meals. 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.V290314.R01.S.doc Version 5.1 Page 9 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.V290314.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is adequate. Sufficient information is not provided to all service users to enable them to make an informed choice about living at Ross House. The assessment process has not been tested in practice. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The service user guide has been redrafted but has not yet been given to service users. Copies of the statement of purpose and service user guide have been forwarded to the commission and are retained on file. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 11 One of the care files examined had evidence of a pre-admission assessment having taken place. The manager stated that there had been no new admissions since her appointment at the home. An assessment format is in place and will be used for all new admissions. The requirements identified on previous inspections are repeated until a time when they can be monitored. Local authority assessments were in place. There was no record of the different treatments or care management for people with mental health needs specific to the individual. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 12 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, 10 Quality in this outcome area is adequate. Shortfalls in the recording on service users’ care plans places them at risk of not receiving the care and support they need. Medication was not recorded correctly. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A care plan was in place in service users’ files examined. The care plan included a risk assessment and detailed a record of a review of the care provided. The care plan continues to need development to detail the specifics of the care provided for the individual. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 13 A record is maintained of GP visits and optical checks within service users’ care files. Service users were confident that if and when they needed health care visits, this would be arranged by the home. One service user who was unwell had asked the home to get the doctor and said she felt much better having seen him, she remarked on how quickly this was arranged by the home. Two comment cards received from GP’s who visit the home indicated that the home communicates clearly and works in partnership with them. Both also indicated that management now take appropriate decisions when they can no longer manage the care needs of the service user. All relative comment cards stated that they are kept informed of important matters affecting their cared for service user and that they were consulted about their care. Five comment cards said they were satisfied with the overall care provided at Ross House. Service users’ weights are undertaken monthly, with a record maintained of weight gain or loss. One service user said they felt happier that their weight was being monitored. Medication administration was observed for a number of service users. Staff took into account the service users’ abilities and prompted and encouraged service users to take their prescribed medication. Improvements have been made in the storage and recording of medication which safeguards service users’ health and wellbeing. The recordings within the medication records needs to be further improved to ensure they meet with the policy guidance. Staff have had additional training with regard to medication and have also commenced a 12 week in-depth medication training course to further develop their skills. District Nursing staff attend the home to provide health care to a number of service users. One was concerned that she was not given enough information to enable the health needs of a service user to be fully met. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. Service users do not have enough planned or structured opportunities to socialise and choice is limited in routines. Poor provision of meals has the potential for service users to receive inadequate diet. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: 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. Liquidised diets were poorly presented with no identification of different components of the meal. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 15 A record is maintained of the food served so that a judgement can be made if the diet is satisfactory. Staff were observed assisting service users to eat their meal with sensitivity and patience. Meals were served on plastic plates which some service users had difficulty using, as they were light and didn’t stay still whilst they were eating. One service user had a great deal of difficulty eating her breakfast as a result of this. Most service users were observed sitting in the lounges for long periods, with no opportunities being provided for mental or physical stimulation. An activities co-ordinator has been appointed to the home. 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 home needs to be proactive in its commitment and efforts to stimulate service users and provide activity inside and outside the home. Comment cards from relatives and staff indicated that there was a need for service users to be involved or have the opportunity to take part in additional activity. Service users were able to receive visitors at any reasonable time. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. Procedures for dealing with complaints were in place, however the recording needs to be improved. Not all staff have had training in adult protection procedures. This judgement has been made using available evidence, including a visit to this service. Important key national minimum standards are not fully met. EVIDENCE: The home has a complaints policy and procedure. There were no recorded complaints since the last inspection. A complaint received at the home in October 2005 had a note attached that this was passed for action in March 2006. One comment card said “there has been an improvement since I formally complained to them regarding aspects of their care.” Two comment cards said they were not aware of the home’s complaints procedure, whilst two others said they were and had made complaints. The abuse policies and procedures continue to need development. Reference should be taken from recognised publications and the local authority’s adult protection procedures and protocols to assist in this development. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 17 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. Some staff spoken to were aware of what constitutes abuse and how to recognise signs of abuse. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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 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 Quality in this outcome area is adequate. The maintenance of the house was not wholly satisfactory. There were some improvements to the cleanliness and odours within the house. This judgement has been made using available evidence, including a visit to this service. Important key national minimum standards are not fully met. EVIDENCE: Inspection of the premises identified that about 17 of the service users’ bedrooms have been painted and some have had new curtains and duvet covers purchased. New carpets have been fitted in a couple of the bedrooms. The bedrooms inspected looked and smelt clean. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 19 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. Previous inspections have described the malodours in the home, which were offensive. There have been some improvements to this, although there continues to be an odour. The registered person has informed CSCI that they plan to undertake a refurbishment of the home and demolish certain areas and extend others. At the inspection it was envisaged that work would commence within the next three weeks. Staff were looking forward to the upgrade and felt that an improved environment would further enhance the comfort provided to service users. All the bathrooms are now operational which provides service users with a choice of bathroom and also means that baths are provided to service users more frequently. 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. Carpets in the hallways were ill fitting. The lighting in the main areas of the home has improved and makes the rooms look a lot brighter, providing lighting for service users to read or take part in other activity as they choose. Fluorescent lighting remains in place in parts of the building. Such lighting is unsuitable for constant use in areas used by service users. The fire authority identified that some work needed to be undertaken in the home to meet fire regulations. A second visit by the fire officer has identified that there are specific rooms which service users must not accommodate until essential work has been undertaken. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. The improvements in the morale and direction of the staff team promote the health, safety and wellbeing of service users. Staff induction and foundation training require implementation. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of staff files identified that they contained a completed application form. All had two written references but these were from India and were “to whom it may concern”, there was no record that these had been verified. Two staff files had a Criminal Record Bureau check (CRB), the third, a POVA first check. One of the CRB checks was a standard check, which is not the level required for staff providing care to service users. A number of staff who have been at the home for a number of years continue to be without Criminal Record Bureau checks. Staff said they had completed the necessary paperwork a long time ago but nothing has been received back. None of the staff files examined had a record of any disciplinary action. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 21 There was no evidence of staff having had induction training to care skills specification. The manager said she is to work on an induction package for new staff. In fairness to the manager, no staff have commenced employment since she started to work at the home. None of the staff files looked at contained a record of staff appraisal or supervision. The manager said the appraisals had started and the inspector had chosen three where they had not had this. Staff said the manager has spoken with them individually and some staff informed the inspector they had received supervision. A staff meeting was organised in October 2005. The acting manager stated that it was her intention to arrange one now she is more familiar with the service users, staff and the home. Staff said the acting manager has worked on the floor alongside them and sits in all the handovers so she is aware of the service users and their needs and is aware of staff skills and abilities. Staff said they were much happier, now work well as a team and communicate better. One staff member said, “the manager was strict but fair”. From observations, the staff team did appear to work better together and there was a good mix of conversation, interaction and humour with service users. The home is currently trying to collate staff training to see what staff have had and arrange training to meet the shortfall. These records appear to be no longer at the home or cannot be located. Moving and handling techniques need to be developed so staff are using the same routine with service users. One of the staff files contained a certificate for moving and handling the other two examined did not. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. The appointment of a 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: One comment card said that, “we feel that Ross House will improve now that new management have been put in place.” A further comment card indicated, “Since the manager and deputy took over there has been a vast improvement. Things are definitely on the up”.
Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 23 An additional comment card said “the home went through a ‘purple patch’ in first six months of 2005 but has improved immensely in recent months, mainly due to new management”. Staff appeared confident in the manager’s abilities. 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. The handyman who has been recently appointed is taking the lead on undertaking fire safety checks. He needs to be familiar with the routines and expectations to ensure he is aware of what he is checking. Examination of the records of service users’ personal allowances identified that receipts were not always in place for purchases made on behalf of service users. The records did not always detail what the withdrawal was for. This needs to be tightened up to safeguard service users and staff. The accident book contained the detail of accidents, incidents and occurrences experienced by service users. How the home is maintaining these records does not comply with Data Protection legislation. An accident analysis was in place up to the end of December 2005. Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 24 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 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 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 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X X 2 X X 2 Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 25 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, 31/08/05 and 31/12/05 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, 31/08/05 and 15/11/05 not met). (No admissions since new manager in post). 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, 31/08/05 and 30/12/05 not met). (There have been no admissions since new manager in post). Timescale for action 25/05/06 2 OP3 14 31/05/06 3 OP3 14 25/05/06 Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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. 4 Standard OP4 Regulation 18(1)(c) Requirement Timescale for action 25/05/06 5 OP7 15 6 OP9 13 & 18 7 OP12 12(2)(3) The registered person must 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, 30/08/05 and 31/01/06 not met). The registered person must 25/06/06 ensure that the care plan details all assessed needs of service users, including the activity, occupation and stimulation which is appropriate for each person. (Timescales of 31/08/05 and 31/01/06 not met). The registered person must 25/06/06 ensure that all staff members employed by the home, with responsibility for medication administration have received appropriate and up to date training. (Timescale of 22/03/06 not met). The registered person must, in 25/06/06 consultation with service users and their representatives or visitors, provide occupation, activity and stimulation. (Timescale of 31/01/06 not met). Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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. 8 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 and 31/01/06 not met). The registered person must arrange for all staff to attend training in what constitutes abuse. (Timescale of 31/01/06 not met). The registered person must ensure that the home is clean and odour free. (Timescales of 28/02/05, 31/08/05 and 31/01/06 not met). The registered person must adhere to the requirements as issued by the Fire Authority. The registered person must redecorate the walls and replace the flooring in the laundry. (Timescales of 31/08/05 and 31/01/06 not met). The registered person must ensure that a policy and procedure for the prevention of infection is written and implemented within the home. (Timescale of 20/10/05 not met). Timescale for action 25/06/06 9 OP18 13(6) 25/06/06 10 OP19 18(1) 23(2) 25/06/06 11 12 OP25 OP26 23 16(2) 23(2) 20/07/06 25/06/06 13 OP26 13 25/05/06 Ross House DS0000008587.V290314.R01.S.doc Version 5.1 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. 14 Standard OP29 Regulation 19 Sch 2 Requirement The registered person must obtain for each member of staff a copy of their 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, 31/08/05 and 31/01/06 not met). The registered person must ensure that enhanced criminal record bureau checks are obtained for all care staff employed at the home. 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, 31/08/05 and 30/11/05 not met). The registered person must ensure that the CSCI is notified of events that affect the health, safety and wellbeing of service users, as defined within the regulations. Timescale for action 31/05/06 15 OP30 19 26/05/06 16 OP30 18 31/05/06 17 OP38 37 25/04/06 Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 29 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. 18 Standard OP38 Regulation 23 Requirement The registered person must ensure that all staff, when next on duty, undertakes a fire drill and practice and these are undertaken at a minimum of twice yearly. (Timescale of 15/11/05 not met). The registered person must provide the handyman with specialist training to enable him to undertake his role efficiently in fire procedures The registered person must ensure that the accident records are kept in line with Data Protection legislation. Timescale for action 25/04/06 19 OP38 23 25/05/06 20 OP38 Sch 3 25/04/06 Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 30 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 ensure that the directions of medication prescribed as ‘as directed’ are clarified with the resident’s General Practitioner and the prescriptions altered accordingly. The registered person should consider maintaining a record of the individual circumstances or behaviours that indicate when ‘when required’ anti-psychotic or analgesic medication may be required. 3 4 OP21 OP24 5 OP9 6 OP9 Ross House DS0000008587.V290314.R01.S.doc Version 5.1 Page 31 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.V290314.R01.S.doc Version 5.1 Page 32 - 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!
