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Inspection on 16/06/06 for Probert Court Continuing Care Home

Also see our care home review for Probert Court Continuing Care Home for more information

This inspection was carried out on 16th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere within the home is warm and friendly and the staff group appear to communicate well with residents. Residents who were able to speak with the inspector expressed the views that they feel safe and well cared for at Probert Court. The standard of cleanliness and presentation of the home is good.

What has improved since the last inspection?

There was little evidence of improvement since the last inspection; this lack of progress is of concern to CSCI.

What the care home could do better:

Residents that were case tracked did not have care plans in place, this meant that there were no systems in place for describing how staff were to meet the needs of individuals or to evaluate the care given. Poor quality in the recording of assessments and completion of care plans had already been identified at the inspections undertaken in October 2005 and March 2006 and the home has failed to initiate improvements in this area. Formal supervision of staff has not been maintained. Staff need to be able to assess, plan, provide and monitor the outcomes for service users; supervision brings together all these practices and ensures that staff are competent to do their job and that competency is maintained. Staff files did not contain the required information in respect of preemployment checks or evidence of training undertaken, this means that CSCI cannot confirm that the home has a robust recruitment procedure or provide adequate induction and training for staff. During a tour of the home it was identified that bed rails in use were not fitted in accordance with relevant guidance, potentially putting residents at risk of injury. The home is required to ensure that staff responsible for selecting and fitting bedrails receive appropriate training. As a result of the above findings, a total of 15 Statutory Requirements were made to improve the service Probert Court provides. CSCI will be closely monitoring the progress the home makes to address these issues

CARE HOMES FOR OLDER PEOPLE Probert Court Continuing Care Home Probert Road Oxley Wolverhampton West Midlands WV10 6UF Lead Inspector Rosalind Dennis Key Unannounced Inspection 10:00 16th June 2006 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 Probert Court Continuing Care Home DS0000017198.V297396.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. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Probert Court Continuing Care Home Address Probert Road Oxley Wolverhampton West Midlands WV10 6UF 01902 444067 01902 444068 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) Heanton Care Housing Association Limited Jayne Margaret Lilley Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2006 Brief Description of the Service: Probert Court is a care home providing accommodation, personal and nursing care to 25 older people. It provides a service to people who have continuing care needs. The home has two designated respite care beds. It is owned by Wolverhampton Primary Care Trust and is one of a group of homes in the district and was first registered in February 2001. The home is situated in the Oxley area of Wolverhampton, a short distance away from local shops and amenities. The single storey building was purpose built, with twenty one single occupancy bedrooms with two double rooms. The communal areas inside the home are spacious and homely in character. The gardens are easily accessible for service users and are secure. Individuals are generally referred via a consultant, with fees paid via the Primary Care Trust. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection to Probert Court lasted approximately seven hours and all key standards were assessed during this time. The inspection involved speaking with residents, staff and visitors, observation of a random selection of resident’s bedrooms, looking at care records and observation of documents. The manager was not on duty at the time of inspection, the deputy manager and staff were fully co-operative and eager to assist. Staff were observed to be attentive to resident’s needs and residents appeared content and well cared for. The assistant director arrived for the latter part of the inspection, which gave opportunity for feedback and to discuss the outcome of the inspection. Two immediate requirement notifications were issued at this inspection in respect of bed rails and care planning. What the service does well: What has improved since the last inspection? There was little evidence of improvement since the last inspection; this lack of progress is of concern to CSCI. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 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. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The process of acting on pre-admission assessments is poor and does not demonstrate how residents needs will be met. EVIDENCE: Two residents care files that were examined showed that a written assessment had been undertaken prior to these individuals being admitted to the home. However the home had failed to use the information provided in these assessments to plan the care required by these individuals, including lack of information regarding the care and management of an individual with diabetes. The home had applied to vary its registration to accommodate two intermediate care beds. Due to the deficits described within this report it is considered by CSCI that it is not appropriate for the home to offer this service at this time, the home has since taken the decision to withdraw the application. The home continues to provide a “step-down” facility from hospital and not the intensive rehabilitation associated with intermediate care. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 9 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 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a process in place for planning care, this places individuals at risk of not receiving appropriate care in relation to their needs. The administration of medication is generally good, however the storage of medication requiring refrigeration is not satisfactory and this could impact on the effectiveness of the drugs and put service users at risk. EVIDENCE: Four residents care files that were observed did not have any care plans drawn up, this meant that there were no systems in place for describing how staff were to meet the needs of individuals or to evaluate the care given. In addition, there was no evidence to show the home had involved residents and family members in the planning of care. One resident with a specific infection did not have a care plan in place or written guidance for staff as to how they should manage the infection. The same resident is diabetic and there was no care plan regarding the Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 10 management of the individual’s diabetes or catheter. A resident that is epileptic did not have a care plan regarding safe management of this condition. Care records did not contain care plans relating to the promotion of skin integrity and a moving and handling assessment was not in place for a resident that requires the use of a hoist. Residents have an “activities of daily living record” on file however this does not give any direction to staff as to the care to be provided-these were noted not to be signed or dated therefore it could not be established when they were drawn up. One individual case tracked had information regarding a type of wound dressing included in the “activities of daily living” sheet, however a wound care plan had not been drawn up. Examination of the daily recorded entries for this person showed that some days a wound dressing had been applied-although it did not always say where to-then from the 11th June 2006 to the day of this inspection there was no record of an assessment being made of this individual’s pressure areas or confirmation of the wound being redressed. This is considered a serious oversight considering that the pressure sore risk assessment documents this individual at high risk of developing pressure sores. The inspection on 17th October 2005 identified that the lack of a consistent care planning process was placing service users at risk of not receiving appropriate care in relation to their needs and, at the inspection on 16th March 2006 the quality of completion of care plans was judged as poor. It is concerning that there has not been any progress to address these deficits, in view of the type and amount of these shortfalls an immediate requirement notification was issued informing the provider that prompt action must be undertaken. Bed rail risk assessments were seen in files and fluid intake/positional charts were seen in the rooms of those individuals identified as at risk. Residents that were spoken with commented that they feel well cared for and the staff respect their privacy. The medication room and drugs trolley were observed to be well organised and observation of medication administration records (MAR) sheets showed these to be completed accurately. Observation of the drugs fridge temperature records showed that the temperature of the fridge was below the required range of 2°C-8°C. Staff had consistently recorded the minimum temperature as -1°C but had not taken any action to increase the temperature; this suggests that the staff recording the temperature are not aware of the required temperature range. On the day of this inspection the temperature of the medication room was satisfactory, however the home needs to start monitoring and recording the temperature to ensure that it is consistently below 25°C Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 11 Two full oxygen cylinders were observed free-standing and not chained to the wall and the Sharps box had not been dated or signed on assembly; this had been identified for action at the inspection in October 2005. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 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, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides social and recreational activities that provide variation and interest for people living in the home. Individuals are offered a varied and well-balanced diet, which takes into account individual likes and dislikes. EVIDENCE: Residents that were able to speak with the inspector described different activities that are provided by the home such as bingo, quizzes, music and movement and residents confirmed that sufficient activities are provided. The home does not have a person employed specifically for the purpose of providing activities and the organisation of individual activities is provided by staff on a daily basis. Staff record activities that residents have been involved in, however feedback from residents suggests that more is provided then is actually documented within the home’s “activities book”. The manager is advised to audit activities to ensure that a full range of activities are consistently offered. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 13 Residents and one relative confirmed that the choice and quality of meals is good, observation of a menu plan showed that a varied, nutritious diet is offered. During the inspection staff were observed to give individuals appropriate assistance with their diet and fluids. The main home kitchen was not observed on this occasion. Throughout the day residents confirmed that they were offered choices, although one individual did comment that she had been “got up” too early that morning. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure in place, which ensures that residents and/or their significant others are listened to and their concerns acted upon robustly. The arrangement for the protection of adults from abuse is almost adequate. In order for home to demonstrate that it has a robust adult protection procedure, the staff group need to have access to the local area adult protection policy and be fully aware of the contact details of whom to contact should any concerns arise. EVIDENCE: The complaints procedure is detailed in the service user guide and is also on display in the reception area of the home. The Deputy manager informed that there had not been any recent complaints and CSCI have also not received any complaints in respect of the home. Residents and relatives that were spoken with reported that they would notify the manager or deputy manager if they were unhappy with any aspect of their care. The deputy manager was able to give a good account of adult protection processes and two staff confirmed that they had attended training in adult protection/abuse awareness and could describe relevant procedures. However there was no evidence of certificates to confirm attendance at training and the home’s “training cards” were noted to be out of date. Staff were not aware as Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 15 to where they could locate the local area adult protection policy or the contact details of the adult protection team. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing residents with a comfortable place to live, however further consideration is needed to ensure that staff have access to infection control policies and procedures. EVIDENCE: A random selection of individual bedrooms and communal rooms were observed to be clean and without unpleasant odour. Residents commented on how the home is always kept clean and tidy and were pleased with the accommodation provided. Discussions with staff confirmed their awareness of the importance of day-today routines to promote good standards of infection control and the home provides hand-washing facilities in all areas of the home. As described earlier in this report a resident with a specific infection did not have a care plan in place or written guidance for staff as to how they should manage the infection. The “activities of daily living sheet” for this individual details “the Barrier Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 17 Nursing Policy must therefore be adhered to” however, although staff were aware that the individual needed to be barrier nursed a copy of the policy could not be located within the home. The deputy manager informed that a member of staff is planning to attend meetings with the local infection control team, this will assist the home to keep to keep up to date with current developments regarding infection control. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not meet the legislative requirement to keep all information and documents in respect of persons working in the home available for inspection, therefore CSCI cannot confirm that the home has a robust recruitment procedure or provide adequate induction and training for staff. Staffing levels appear sufficient to meet the needs of individuals currently residing at the home. EVIDENCE: Discussion with the deputy manager and observation of staffing rotas confirms that staffing levels within the home are; 1 Nurse and 6 carers in the morning, 1 Nurse and 4 carers pm and at night there is 1 Nurse and 2 carers. The manager is supernumerary. The structure of the shifts ensures that there is an “overlap” of staff at the beginning and end of each shift; this is good practice as staff commented that it enables them to have a full handover regarding resident’s needs. Residents that were spoken with felt that the staffing levels were generally sufficient. Catering staff are employed daily although staff assist with meal preparation in the evenings at weekends, staff that were spoken with did not feel that this compromised care and felt that staffing levels were adequate each day. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 19 Information regarding pre-employment checks is reportedly kept centrally at Springvale House, however a lack of information within the four staff files that were seen by the inspector means that CSCI is unable to confirm whether the home has a robust recruitment procedure. One file contained an application form but no references, another file just contained confirmation of the start date of employment for the individual and it could not be evidenced whether CRB Disclosures had been attained for three of the four individuals prior to employment. The assistant director confirmed that the home is in the process of reviewing the recruitment processes and is intending for information to be available within staff files. The file for a recently appointed member of staff did not contain any documentation in respect of the individual’s induction. It was suggested at the inspection in March 2006 that the manager records any training undertaken by staff on a “training matrix”, rather than on individual training cards. It was observed that a matrix for 2006/07 had recently been drawn up and this should assist with the planning and review of training. Two members of staff commented that they are provided with training opportunities and supported to attain NVQ, however because staff training certificates were not available and the current method of recording training was not up to date, this could not be confirmed. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 20 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, 36, 37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The failings in a number of key areas described elsewhere in this report demonstrate a lack of appropriate management and effective quality monitoring within the service. Residents views are sought in respect of the operation of the home, however poor care planning systems are potentially placing individuals at risk and require prompt action by the provider. The home is well- maintained however further consideration is required promptly regarding the safe use of bed rails. Improvements to staff supervision are still required in order to ensure that staff remain competent in their respective roles. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 21 EVIDENCE: Although the manager was not on duty at the time of inspection, it has been identified at previous inspections that she has the experience and knowledge for the current client group. Regular meetings are held with residents and/or their representatives and minutes are available for individuals that are unable to attend. Observation of minutes from staff meetings demonstrate that the managers and staff are very much focussed on ensuring that residents and relatives receive good quality care, the home now needs to provide documentary evidence through its record keeping that it is meeting the needs of the people accommodated. The home operates a quality assurance system based on seeking the views of residents where capable and/or their representatives. Results of the last quality survey were seen at the last inspection. Senior management conduct comprehensive monthly, unannounced visits of the home and a copy of this report is sent through to CSCI. It is noted that these visits have previously recognised some of the deficits identified in this report. Formal staff supervision has not been consistently carried out for all staff. Changes within the supervisor/supervisee system has recently occurred within the home, however a commitment to ensuring that all staff have access to regular formal supervision must be seen as a priority. During the inspection it was apparent that the environment is well-maintained and observation of records demonstrates that equipment is serviced regularly. However not all bedrails observed in use were fitted in accordance with the Medical Devices Agency guidance (July 2001). Two beds were observed to have pressure-relieving mattresses placed on the top of an ordinary mattress and the bed rails in use were not of a sufficient height to maintain their effectiveness-one resident was observed asleep in one of these beds-the additional height of the pressure overlay system was placing this individual at considerable risk of rolling over the top of the 3 bar bed rail. Two bed rails were fitted with an excessive gap at the head end, creating a potential entrapment hazard. This led to an immediate requirement notification being issued and the assistant director confirmed that action would be taken immediately to ensure that bed rails were fitted correctly. The home must ensure that staff who are responsible for the selecting, fitting and checking of bed rails receive appropriate training and that the general maintenance of bed rail assemblies is incorporated into a planned preventative maintenance programme. Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 2 2 Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(A) Requirement The registered person shall provide to each service user, by not later than the day on which he becomes a service user, a statement specifying the fees payable by or in respect of the service user of the services of the home. This shall include the method of payment of the fees and the person or persons by whom the fees are payable. (Not assessed at this inspectionprevious timescale of 31/12/04) Timescale for action 16/08/06 2. OP3 14 The registered person must ensure assessments of need and risk are completed. (Timescale of 30/06/06 not met) 01/08/06 3. OP7 15 (1)(2) The registered person shall 01/08/06 ensure that care plans give clear, consistent information and are developed in consultation with relevant others at all times. (No care plans in place, therefore timescale of 30/06/06 not met) 4 OP8 12 The home must ensure that assessment and care planning systems, training and skills are in place so that service users health needs are met. (Timescale of 17/01/06 from 01/07/06 Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 24 October 2005 inspection not met) 5 OP9 13(2) All stored oxygen must be securely chained against the wall. 01/08/06 (Previous timescale of 17/11/05 from October 2005 report not met) 6 OP9 13(2) Sharps boxes must contain completed details of opening, by whom and date of closure 01/08/06 (Previous timescale of 17/11/05 from October 2005 report not met) 7 OP9 13(2) 8 OP18 13(6) 9 OP26 13(3) 10 OP29 19 11 OP30 17 Schedule 4 The temperature of the drugs fridge must be maintained at between 2 and 8°C and the registered person must ensure that staff are aware of the required temperature range and of the procedure to follow should the temperature fall outside this range. The temperature of the treatment room must also be monitored to ensure it does not exceed 25°C. The registered person must ensure that staff are aware of the local area adult protection policy and the contact details of whom to contact should an incident arise. Barrier nursing protocols in the home must be readily available for staff. These protocols must meet the Health Protection Agency guidelines. The registered person must ensure that information and documents as required by Regulation 19 Schedule 2 are retained on each staff file. If certain documentation is to be retained within a centralised department then written agreement with CSCI must be sought. The registered person must ensure that a copy of the employee’s induction is retained in order to confirm that the DS0000017198.V297396.R01.S.doc 01/08/06 01/09/06 01/08/06 01/09/06 01/09/06 Probert Court Continuing Care Home Version 5.2 Page 25 12 OP30 18, 17. 13 OP36 18(2) induction provided by the home is sufficient. Documentation in respect of 01/09/06 individual training needs must be kept up to date in order to clearly show staff fully meet the needs of all residents, including mandatory training. The registered person shall 01/09/06 ensure that staff receive appropriate supervision and that it is recorded (Previous timescale of 19/08/04 not met) 14 OP37 17 15 OP38 18 13(4)(c) Up to date records must be 01/09/06 maintained in the home for residents and staff as identified in Schedules 3 and 4. Staff who are responsible for 01/09/06 selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be included on a planned maintenance schedule. 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 3 4. Refer to Standard OP8 OP13 OP26 OP30 Good Practice Recommendations Photographs should be used as a method of monitoring wounds, treatment and outcome unless the resident’s consent cannot be obtained. The manager is advised to audit the activities provided by the home. The registered person is advised to consult with the local infection control specialist to ensure that practices within the home follow current infection control guidelines To produce a matrix to monitor the provision of training (in progress). Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Probert Court Continuing Care Home DS0000017198.V297396.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!