Inspection on 28/01/08 for Raj Nursing Home

This inspection was carried out on 28th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Raj Nursing Home 17/11/08

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

CARE HOMES FOR OLDER PEOPLE Raj Nursing Home 31,33 & 35 Osterley Park Road Southall Middlesex UB2 4BN Lead Inspector Rekha Bhardwa Key Unannounced Inspection 11:10 28 & 29th January 2008 th 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 Raj Nursing Home DS0000070839.V356513.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. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Raj Nursing Home Address 31,33 & 35 Osterley Park Road Southall Middlesex UB2 4BN 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) 020 8574 1795 020 8813 9292 St Dominic`s Ltd vacant post Care Home 24 Category(ies) of Dementia (24) registration, with number of places Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 24 First Inspection since registered with Aster Healthcare. St Dominic’s is part of this Company. Date of last inspection Brief Description of the Service: Raj Nursing Home is a conversion of three houses into one home and is situated in a residential area of Southall. There are some shops near to the home and the home can be accessed by bus. The home specifically caters for Asian and ethnic minority residents with dementia, mental health or physical disability healthcare needs. The home has thirteen single and five double bedrooms with plans to convert a number of double rooms to singles. There is a spacious day room and a prayer room situated at the end of the garden. The home is near to the local Temple and Gurdwara. The food provision is specific to the residents cultural, religious and dietary needs. The staff employed at the home collectively speaks several languages and dialects to cater for the communication needs of the residents at the home. The fee’s range from £550 - £700 per week. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 12 hours was spent on the inspection process. One CSCI Regulation Inspector carried out the inspection. This was the first inspection of the home since it was purchased by Aster Healthcare Limited in September 2007. A tour of the home was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. 5 residents, 5 staff and 3 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home has also been used to inform this report. 3 comment cards for visitors were returned and have been used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of residents with mental health or dementia care needs. What the service does well: What has improved since the last inspection? What they could do better: Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 6 Shortfalls were identified in the formulation, review and updating of the service user plans. This included care plans, continence assessments, moving & handling assessments, use of bedrails, nutritional assessments and the overall recording and updating of information. There is little or no involvement in the formulation and review of the service user plan documentation by the resident or their representative. Residents wishes in respect of a deteriorating condition and end of life care needs have not always been ascertained. Care plans were not in place to identify residents individual social and leisure interests. The home does not have an activities programme to meet the individual preferences of the residents. Information on advocacy is not freely available. The overall standard of the environment is poor. This has already been identified by the new owners of the home. An environmental audit must be carried out from which the redecoration and refurbishment plan can be updated with timescales for completion. Toiletries were found in two bathrooms, and the need to ensure toiletries are kept in residents own rooms was discussed. The overall cleanliness and odour control within the home was poor and did not provide a pleasant environment for residents to live in. Shortfalls have been identified in the training provision in the home to include health and safety training and training in relation to the care needs of the residents living at the home. A robust quality assurance system must be implemented. Regular servicing of equipment within the home must take place at the required intervals. Risk management systems must be reviewed in order that the health and safety needs of the home are being fully met. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Raj Nursing Home DS0000070839.V356513.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 Raj Nursing Home DS0000070839.V356513.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose has been updated to provide an accurate picture of the services provided by the home. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The Manager Designate said that the Statement of Purpose had been fully updated since the new providers had taken over. Prospective residents are fully assessed prior to admission to ascertain if the home is able to meet their needs, and samples of pre-admission assessments were viewed and both had been fully completed. The home also obtains copies of the Social Services needs led assessment for each person. Raj Nursing Home DS0000070839.V356513.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls have been identified in the formulation and update of service user plans, thus a full picture of the needs of residents living at the home and how these are to be met is not always available. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a caring, gentle and professional manner, thus respecting their privacy and dignity. Information regarding the wishes of residents and their families in respect of end of life care is not always ascertained, thus residents are at risk of not having their needs in this area fully met. EVIDENCE: Two service user plans were viewed during the course of the inspection. One service user plan had been signed by the residents representative. For one resident who had returned from hospital newly identified needs had not been incorporated into the care plan. For another resident no care plan was available regarding how behavioural needs were to be managed. Monthly reviews were being carried out. The need to ensure that service user plans are Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 10 individual to the resident was discussed with the Manager Designate. Daily records were well completed. Pressure sore risk assessments were available. Moving and handling assessments had not always been undertaken and care plans to detail the residents mobility needs were not available. Specific equipment required for moving and handling had not been identified. Continence assessments were not available for both service user plans viewed. One nutritional assessment was incomplete and there was evidence of monthly weights being undertaken. Falls risk assessments were available and were being reviewed monthly. The Responsible Individual stated that standardised documentation for care planning would be introduced into the home. Bedrail risk assessments and consent was not available for one resident who was using bedrails. Another bedrail risk assessment viewed did not identify clearly the risks requiring a bedrail. There was evidence of input from the GP and other healthcare professionals, and residents are referred to the GP if any concerns are identified. The inspector viewed the medication management. A list of staff signatures was available. Liquid medications had been dated when opened. Receipts, administration and disposal of medications had been recorded. The fridge and room temperatures were being recorded and were within the required range. Controlled drugs were being appropriately stored and recorded. Stocks were checked for one medication and found to be accurate. Staff were seen caring for residents in a gentle and professional manner and there was good interaction between residents and staff, with a happy atmosphere throughout the home. Residents who were able to expressed their satisfaction with the care they receive at the home. Staff were heard speaking to residents using their preferred term of address and relevant language. Individual clothing is labelled and residents were well dressed, to reflect individuality and cultural needs. Bedrooms are not personalised and did not look homely. Some information was available on one service user plan viewed regarding the residents’ end of life wishes. The need to ensure that this is completed for all residents was discussed with Manager designate. Where an individual had stated that they did not yet wish to discuss this topic, this needed to be recorded. The training matrix viewed indicated that no staff had received training in end of life care. The AQAA completed by the home indicated that this is an area identified as requiring improvement. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not have an activities co-ordinator, and activities are not being provided to meet the needs and interests of the residents. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is not available, thus residents right to independent representation is not being respected. The food provision in the home is good, offering variety and choice, thus meeting the resident’s individual needs. EVIDENCE: The post of activities co-ordinator is vacant and at the time of the inspection there was no activities programme in place. The Manager designate was in the process of recruiting to this position. On both days of the inspection no activities were taking place. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home. Residents can choose whether to receive visitors in their own rooms or in one of the communal areas, as they so wish. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 12 Information regarding advocacy services was not available at the time of the inspection. Brief comment regarding advocacy service provision had been included in the AQAA, but this did not include the actual details of the advocacy services used. The Inspector viewed the kitchen. This was clean and tidy and all the records were up to date. Residents spoken with said that they enjoy their meals and that choices are available, as evidenced on the menu. Snacks and drinks are available throughout the 24-hour period. The home provides both vegetarian and non-vegetarian Asian food. Staff were available to assist residents with their meals and were seen doing so in a gentle and discreet manner. Risk assessments and hazard analysis records were not available in the kitchen. The cook at the time of the inspection had undertaken some food hygiene training and had commenced her NVQ in catering. It was not clear from the information provided what percentage of staff had received training in safe food handling. The cook informed the Inspector that a new fridge and freezer had been ordered. Cleaning records are maintained. The Inspector noted that several areas above the cooker and the extractor fan were greasy and required a deep clean. The Responsible Individual stated that he would arrange for this to be undertaken. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: The AQAA completed by the home detailed that the home had received four complaints in the last 12 months and that all complaints had been resolved within 28 days. The Acting Manager has an ‘open door’ policy for visitors, and does deal promptly with any concerns raised. The home has adult protection policies and procedures in place that dovetail with the Ealing Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. One POVA case had been investigated since the last inspection. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is evidence of works taking place to maintain the home; however additional redecoration and refurbishment programmes are required to provide a good standard of accommodation for residents. The standards of cleanliness throughout the home were poor and do not provide a pleasant environment for the residents to live in. EVIDENCE: The Inspector carried out a tour of the home and viewed the external areas also. The paintwork on the external of the building was peeling off and overall the outside of the premises and several internal areas to include the lounge area looks shabby and in need of redecoration. Some work had been done to convert the Managers office into a single bedroom and a storage area had also been made into a new bedroom. Plans are in place by the new owners to convert several of the double bedrooms into single bedrooms. At the time of the inspection the maintenance person position was vacant and the Manager Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 15 Designate was in the process of recruiting a maintenance person and external contractors were currently undertaking any maintenance issues. Work must be undertaken to redecorate and refurbish the home in line with current dementia research. In one residents bedroom the radiator had been faulty for several months. Little action had been taken to address this. The laundry was clean and tidy. Personal clothing items viewed were labelled. There are two washing machines and one of these has a sluice programme for infection control. There is one tumble dryer and ironing equipment was available. Protective clothing to include gloves and aprons were available in the home. At the time of the inspection a small part of the tumble dryer was being kept in place by some sellotape. The laundry person reported that the tumble dryer had been working intermittently and that this had been reported to the Manager Designate. The Responsible Individual stated that he would address this. The inspector noted malodours in some individual bedrooms and there was no evidence that cleaning staff were addressing these. The standards of cleanliness within the home were poor and it was clear that staff were not cleaning the home thoroughly. This included poor cleanliness in the bathroom and toilet areas, individual bedrooms to include dirty sinks, dust, stains on carpets and generally build up of dirt in the communal areas and furniture. Bottles of shampoo and bubble bath were found in the upstairs bathrooms and this is a potential hazard as several of the residents wander freely in the home. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed and staffing levels are kept under review, thus ensuring that the needs of the residents can be met at all times. Systems for vetting and recruitment practices are in place to safeguard residents. There is an ongoing training programme, however shortfalls in the provision of training in some areas could lead to staff not having the knowledge and skills to meet the full needs of the residents. EVIDENCE: Since the purchase of the home by Aster Healthcare the Responsible Individual has reduced the staffing by one Registered Nurse during the waking day. The Manager Designate stated that she was monitoring this in line with the residents dependency levels. The Responsible Individual also stated that should residents dependency levels change the Manager Designate had the autonomy to increase staffing hours. The possibility of an additional carer during the morning shift was discussed. There were several vacancies within the staff establishment and the Manager Designate was in the process of recruiting into these posts. The Inspector noted that several of the staff working at the home were students who have a limited amount of hours that they can work during term time. The Inspector discussed with the Manager designate the need to ensure that staff members who were students were working there correct hours. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 17 Information provided by the Manager Designate states that over 50 of care staff are qualified to NVQ in care level 2 or the equivalent. The Manager Designate stated that further training would be planned once new care staff had been recruited. The management are very aware of the importance of training and updates to provide staff with the knowledge and skills to meet the needs of the residents. The Inspector viewed 2 sets of staff employment records for staff recently employed at the home. These contained the information required under the Care Home Regulations 2001. It was recommended at the time of the inspection that the files contain a copy of the staff contract and a job description. The home has an induction programme, which is not based on the Skills for Care common induction standards. The Manager Designate stated that she had contacted Skills for Care and had ordered the Induction booklets and was waiting for them to be delivered. The staff training matrix viewed by the Inspector clearly had not been updated and it was apparent that very little training in topics relevant to the diagnoses and needs of the residents had taken place. The Inspector was informed that several of the staff are undertaking information technology training and that the home had been provided with several laptops and the Manager Designate has a computer with internet access. The need to ensure that all staff receive training in dementia care was discussed with the Manager Designate. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the experience to manage the home, and is open and approachable. Systems for quality assurance must be put in place, in order to provide an ongoing process of management and practice review. Shortfalls identified in the management of health & safety at the home could place residents living at the home, visitors and staff at risk. EVIDENCE: There has been a change of ownership and in Manager in September 2007. The Manager Designate has been working at the home for the last three years as the Deputy Care Manager. She is in the process of applying for registration. The Manager Designate is a first level nurse and has several years experience of working with elderly people. She is in the process of completing the Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 19 Registered Manager Award. Plans are in place for her to undertake leadership and managing people training. Comments received from representatives were very positive and it is clear that the home is being well managed. The Registered Manager maintains daily contact with residents and ensures she knows what is going on in the home at any one time. The Responsible Individual stated that Aster Healthcare will be implementing their quality assurance system at Raj Nursing Home along with the Company’s policies and procedures. Regulation 26 visits on behalf of the Responsible Individual are carried out and reports are available. This standard will be assessed in detail at the next inspection. The home does not manage any monies on behalf of the residents. The Responsible Individual stated that only one resident’s monies are being managed from the finance department at the head office. Action is being taken to resolve this issue. The Inspector sampled the maintenance and servicing records and those viewed were up to date, with the exception of the Legionella and Loler testing for the hoists. Training and updates in health & safety topics to include moving & handling, fire safety, first aid, food hygiene and other subjects was not up to date for all staff. Risk assessments for equipment and safe working practices were in place but it was not clear when these had been reviewed. The Responsible Individual stated that Aster Health and Safety policies and procedures were to be introduced into the home. Fire drills had taken place and the fire risk assessment needed to be updated to reflect some of the changes to the building. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? New Service STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Service user plan documentation must be completed in full to provide all necessary information in respect of the individual. A care plan must be completed for each identified need and regular reviews undertaken. Mobility care plans must be in place for all residents that have a moving and handling need. These must clearly record the equipment in use. Input from the resident and/or their representative must be sought for the formulation and review of the service user plans, unless it is impracticable to carry out such consultation. This will ensure the needs and wishes of the resident are clear and can be respected. All assessment documentation must be in place, complete and up to date to give a clear picture of each residents’ condition. Risk assessments for the use of bedrails must clearly identify the reasons for and appropriateness of their use. Written consents DS0000070839.V356513.R01.S.doc Timescale for action 10/03/08 2 OP7 15,13(5) 10/03/08 3 OP7 15 10/03/08 4 OP8 17 10/03/08 5 OP8 13(4)(8) 10/03/08 Raj Nursing Home Version 5.2 Page 22 6 OP11 12 7 OP12 16(2)m,n 8 OP12 15 9 OP14 12 10 OP15 23(2)d 11 OP19 23(2) 12 OP26 23(2)d 13 OP26 13(3) 14 OP30 18 must be obtained. Information regarding service users wishes in the event of deterioration in their health, plus their care in their final days must be ascertained and recorded, so that their wishes are known and respected. There must be in place an activities programme. This must reflect the assessed interests and abilities of the residents and staffing must be appropriate for the activities programme to be carried out on a daily basis, to occupy the residents. Care plans for activities and interests must be completed for each resident, so their needs are identified. Information regarding advocacy services must be freely available to ensure that residents rights are upheld. The kitchen must be periodically deep cleaned in order that food preparation environment is safe and protects the residents and staff. A full environmental audit must be carried out and a redecoration and refurbishment plan drawn up, to reflect all areas requiring work and timescales for completion so that they can be addressed in a timely fashion, providing a good environmental standard throughout. The premises must be kept clean and free from offensive odours in order that residents have a pleasant environment to live in. Personal toiletries must not be left in communal areas in order to ensure the safety of the residents. Staff must receive training in DS0000070839.V356513.R01.S.doc 10/03/08 18/03/08 10/03/08 10/03/08 10/03/08 18/03/08 15/02/08 15/02/08 31/03/08 Page 23 Raj Nursing Home Version 5.2 15 OP33 24 16 OP38 18 17 OP38 23(2)c 18 OP38 23(4) topics relevant to the diagnoses and care needs of the residents to provide them with up to date skills and knowledge to care for them effectively. An action plan to address this must be drawn up. The Responsible Individual must have in place a Quality Assurance System for reviewing and improving the quality of care at the home. There must be evidence that all staff have received training and updates in all aspects of health & safety at the required intervals. All equipment must be regularly serviced at the required intervals to ensure the health and safety of the residents and staff. All risk assessments to include fire, equipment and safe working practices must be reviewed and maintained up to date thereafter to ensure the safety of the residents, staff and visitors. 01/04/08 31/03/08 15/02/08 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations It is recommended that the contracts and staff job descriptions are kept on the individual staff employment files. Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Raj Nursing Home DS0000070839.V356513.R01.S.doc Version 5.2 Page 25 - 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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