Inspection on 12/12/05 for Randolph House Care Centre

This inspection was carried out on 12th December 2005.

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

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

Other inspections for this house

Randolph House Care Centre 05/11/07

Randolph House Care Centre 29/11/06

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Randolph House Care Centre Ferry Road West Scunthorpe North Lincolnshire DN15 8EA Lead Inspector Mrs Kate Emmerson Unannounced Inspection 12th December 2005 09:30a 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 Randolph House Care Centre DS0000066375.V274386.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. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Randolph House Care Centre Address Ferry Road West Scunthorpe North Lincolnshire DN15 8EA 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) 01724 272500 01724 272505 Four Seasons (DFK) Limited Care Home 70 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (51), of places Physical disability (41), Physical disability over 65 years of age (41), Terminally ill (1) Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is able to accept two named service users with Learning Disability and should revert to the original registration as they leave the home. 25 May 2005 Date of last inspection Brief Description of the Service: Randolph House is a dual registered home for residential, and nursing care for older people, there is also one bed registered for terminal care. The home was pleasantly decorated and furnished, and provided a homely atmosphere. The accommodation is provided over two floors, and has a unit on the first floor, which provides specific care for those with Dementia. The first floor is accessible by a lift, and stairs There are good parking facilities to the front of the building, and there are enclosed gardens to the rear and sides of the home. These were well maintained. The home is close to local amenities, including a post office, and general shops. It also has close links to the M180 motorway. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in December 2005. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the manager and 5 of the staff working in the home at the time of the inspection. The inspector also spoke to people who lived in the home and a visitor. Records kept in the home were also seen, this was to make sure that the checks to make sure staff are safe to work in the home were done before they started and that they had been trained to their job safely. Records were looked at to make sure that the home and the things used in it were safe and were checked often. The manager of the home Shirley Hannon had been in charge since 1st December 2005. There were some improvements in the home and the way it was managed. The standards of care were being affected by staffing levels in the home and this must be addressed as soon as possible. What the service does well: What has improved since the last inspection? The information that was given to people about the home had been improved and the home now provided lots of detail about the services available. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 6 A visiting medical professional stated that the care of people with Dementia had improved over the last few months and staff were more knowledgeable. There had been some improvements in decoration the Primrose unit and control of smells in the home had also improved. The equipment used to move people where they were unable to stand had been repaired and new batteries had been bought so that all the equipment was available now. What they could do better: The staff did not always up date how care must be given if someone’s needs had changed to make sure that people living in the home are kept, healthy, safe and comfortable. This is important to make sure that all the staff understand the care that everyone needs and can make sure that the care they are giving is working or not. They must make sure that when people cannot walk about very well they will not get any sores on their skin by assisting them to change position regularly and providing special equipment and they must also provide safe chairs. They must make sure that medication is checked properly when it arrives at the home to make it is correct and they must make sure that records show if someone has been given their medication or not. They must not pay every ones money into one account. The checks to make sure staff were safe to work in the home had not always been done before the staff started work. This puts people living in the home at risk. The home was not as safe as it should be because they did not make sure that oxygen tanks were fastened properly, fire alarms were checked regularly and fire extinguishers were hung in the correct places. They must check accident records to make sure that all risks are identified and then reduced to prevent accidents happening again where possible. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 7 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. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 A wide range of information about the service was provided which was sufficient for service users to make an informed choice about the home. All the service users were assessed prior to moving into the home. Records were detailed and well maintained. EVIDENCE: The home provided information about the service in the form of a statement of purpose, service users guide, colour brochure and information leaflets. These were displayed in the reception area of the home. The statement of purpose had some minor omissions, which were addressed by the manager by the second day of the inspection. The service users guide was informative and user friendly but to meet the standard should also include service users views of the home, further Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 10 information in relation to the manager and her experience and the responsible individuals name, qualifications and experience. The manager stated that she completes all the assessments prior to admission to the home where possible. Random samples of assessments were examined. The assessments were detailed and care plans had been developed from the assessments. The assessment process also included a very detailed social assessment, which recorded the service user preferences in daily routines, diet, and activities. Even where a service user had been admitted in an emergency just prior to the inspection a full assessment and care plan was in place. In only one of the five assessments seen the assessment documentation not been fully completed. The home accepted emergency admissions and had an on call management arrangement to assist this process. The policy and procedure had not been updated prior to the inspection as required at the last inspection but provided to the inspector prior to writing this report. This procedure now provided adequate information for staff regarding the process of accepting an emergency admission to the home. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Although some improvement in the care planning processes could be seen these did not always inform the care practise adequately and this together with poor evaluation of the care provided and lack of appropriate equipment put some service users health and safety at risk. However the new manager was proactive in this area and significant improvement is expected. Service users health and safety may be put at risk due to deficiencies in practise when receiving and administering medication and storage of medication. Service user felt they were treated with respect and had their privacy protected. Policies and procedures and staff training supported this. EVIDENCE: Case tracking of 5 service users was completed. This included examination of care records, discussion with service users where they were able and staff and observation of care practises. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 12 There was improvement in the care plans although due to ineffective evaluation the care plans had not always been updated as needs had changed. For example where there were increased falls, changes in tissue viability or significant events such as an incident of challenging behaviour these had not been detailed in evaluations and the care plans adjusted as required. In one case where a service user had developed a pressure sore and a dressing had been applied the care plan had not been updated to reflect this. Where service users were at risk of pressure sores care plans had not always been developed and monitoring charts were not consistently monitored to ensure that service users had pressure relief at appropriate intervals. Daily diary recordings did not always describe in sufficient detail the care provided or health issues and outcomes/action taken. Some of the care plans had not been dated and there was little evidence that the service users or their representative had agreed to their care plan or risk management plans. Key worker records were inconsistent and the quality of some of the key worker contact recorded was poor. Assisting someone to go to the toilet is not quality key worker time. The new manager was aware of the issues regarding care planning and had commenced a detailed audit of the care plans and action plans were in place were deficiencies had been noted. There was evidence that equipment was not always available to meet service users care needs, which may leave the service users health and safety at risk. In one case it was recorded that a catheter could not be removed, as there were no syringes and in another the nursing staff stated that they had assessed one service user as requiring an airflow mattress but this had not been provided. There was evidence that assessments for appropriate seating had not been requested in a timely manner. There was no service users self-medicating at the time of the inspection due to the dependency of the service users accommodated. However there were policies and procedures and risk assessments in place to support this. Nursing staff were responsible for all aspects of medication in the home. There were records of observed medication rounds with the manager where the nurse’s competency was assessed. Medication records and storage were examined on all three units. Some issues were noted on all the units, which may put service users health and safety at risk. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 13 Primrose unit – In one case Haloperidol was prescribed on the printed administration records as every eight hours but times written as 8am, 5pm and 10pm but on the bottle the prescription was ‘to be given once every eight’. It was not clear if this was a mistake on the bottle or the medication records although no one had noted this when the medication had been received or when administered. Advised staff and the manager to check with the GP as soon as possible. Controlled drugs could not be adequately recorded, as the unit did not have a controlled drug book. Oxygen cylinders were not secured safely even though there was adequate equipment to do so. Poppy unit – twelve gaps in administration records where medications had not been signed as given or a code entered when not given. Bluebell unit - 2 gaps in administration records. Daily checks of medication fridge temperatures to ensure that the medication was being stored safely had not been recorded since the 3 December 2005. Service users who were able to express themselves stated that generally they were treated with respect and privacy was upheld. The manager stated that all the service users were accommodated in single rooms at the time of the inspection due to their personal choices but if rooms were shared a privacy screen would be provided. Service users had access to use of a telephone in private or they could have a telephone in their own room. Service users clothing was labelled and each had a laundry basket to ensure service users wore their own clothes at all times. Preferred terms of address were recorded at the assessment. Staff were provided with training in protecting privacy and dignity during induction. Randolph House Care Centre DS0000066375.V274386.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): 13, 14 and 15 Service users were able to maintain contact with their family and friends and the local community. Service users were able to exercise choice over their lives. Service users were offered good quality nutritious meals but specific details with regard to cultural or religious needs in this area were not recorded. Some service users received inadequate standards of care at meal times due to staffing shortages. EVIDENCE: Service users visitors were made to feel welcome by the staff and information regarding visiting arrangements was provided in the service users guide and statement of purpose. Information with regard to regular visitors and contact details were recorded in the social assessments. Relatives and service users were involved in planning activities in the home together with the homes activities coordinator. The home had a comforts fund committee, which met monthly to discuss activities and funding arrangements. Service users choices were promoted through assessment of preferred daily routines and dietary preferences. However one service user who would have Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 15 had specific needs due to cultural and religious requirements and who was also a vegetarian did not have a care plan to support their dietary needs, the manager could not detail what the service users needs in this area were. The service users stated that they enjoyed their meals and the choice available. They stated there was always a 2 choices available and alternatives if required. There were 3 courses provided at lunch and teatime. The lunch meal was observed; the spacious dining room was well presented with condiments and napkins on each table. The food was provided in a variety of portion sizes and pureed fresh food was available as required. The staff group on the Bluebell and Poppy units were well organised with the afternoon staff coming on to overlap with morning staff over the lunch period. This enabled the lunch to be served efficiently with sufficient staff to assist were required. However, due to staffing shortages there were only four staff on the Primrose unit to assist at lunchtime despite the overlap. Lunchtime in this area was rushed with staff having little time to give assistance where required. Eight service users required assistance with feeding and one-service user, due to specific difficulties with positioning, took at least half an hour to assist and would have benefited from the assistance of two carers. One of the four staff had to plate and serve the meals from the heated trolley. It was observed that staff were standing to feed service users and flitting between service users or assisting them as they passed. The service users were not offered a drink until after their meals. This standard of care is not acceptable and especially with service users with dementia who require a high level of support and supervision to ensure an adequate diet is taken. Randolph House Care Centre DS0000066375.V274386.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): 18 The home had systems in place to protect vulnerable adults but must ensure that all staff have received training in this area and local POVA procedures are implemented. EVIDENCE: Half the staff group had received training in the protection of vulnerable adults and all spoken with displayed knowledge in the recognition of abuse. They all gave acceptable responses to the action that they would take in the event of suspicion of abuse. The home had a variety policies and procedures to protect vulnerable adults. A copy of the Local Authority protection of vulnerable adult procedures was available in the home but was out of date, a new copy needs to be obtained and adhered to in terms of referral and investigation of allegations or suspicion of abuse. The new manager had attended managers training with the Local Authority in her previous role. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 17 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, 22 and 26 The cleanliness and odour control in the home had improved since the last inspection but the standard of décor varied through the home. The environment in the Primrose unit would benefit from further development to meet the specific needs of service users with dementia. Service users health and safety was being put at risk due a lack of appropriate seating in the home. Safety in the home may be compromised due to the removal of fire extinguishers from wall brackets in the Primrose unit. EVIDENCE: The home provided comfortable homely accommodation with a variety of communal space for the service users to enjoy. The gardens were well maintained and accessible. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 18 The home was generally clean tidy and odour free. In the entrance hall, odour control had improved and the chairs were clean and this now provided a pleasant area, which was used throughout the inspection by service users. There was a distinct difference in the standard of décor between the Primrose unit and the rest of the home. However the company had made some improvements in the unit by fitting a new kitchen area in the dinning room. People with dementia have particular needs for the layout of communal space and associated signage, which aid their remaining capacity and encourage continued independence. The service users in this unit would benefit from more thought being given to this. There was evidence that service users were seated in chairs that were not suitable for them and put their health and safety at risk. An occupational therapy assessment had been requested for one service user but a more proactive approach is needed in this area as the management had been advised of deficiencies in this area at the last inspection and records showed ongoing problems. Fire extinguishers in the Primrose unit had been removed form their wall mountings and stored in the shower room and behind the nurses station. The nurse stated that this had been done to prevent service users touching them. This is not appropriate action and advice must be taken from the fire officer for options to secure the extinguishers and maintain safety. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 19 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): The staffing levels were not consistently maintained to adequately meet the needs of the service users and an immediate requirement notice was served for this to be addressed. The staff received training appropriate to their role and a training plan had been developed. Where deficiencies in training provision had been identified, training had been arranged to address this. There was a commitment form staff and management to NVQ training. There was evidence that not all the checks to ensure staff are safe to work with service users had been obtained prior to employment. This does not afford adequate protection for service users living in the home. EVIDENCE: The home was divided into 3 areas for arranging the staff group. Each area should have had 1 nurse and at least 3 carers on duty during the day. There was evidence from records and discussions with staff that these staffing levels were not consistently maintained in the home and each unit was regularly short staffed. There was evidence during the inspection that there was insufficient supervision and assistance for the service users when they were sat in the communal areas and during meal times. The manager confirmed that the company provided sufficient budgets for staffing to be maintained but that there were insufficient staff to cover the rota and staff Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 20 sickness had also impacted on the staffing levels. There was also a staff member who was requiring supervision by other staff and could not fulfil the job description of a carer but who was still counted in the carer’s numbers on the rota. A review of the staff member’s capabilities was being conducted by the home. The manager had identified the staff training needs and had implemented a training plan to meet mandatory and service user specific training requirements for 2006. Carers and nursing staff identified a variety of training, which they had attended over the last year and stated that there was a rolling programme of manual handling training. Staff training records showed that sixteen staff had not received moving and handling training in the past year but two of the nurses had completed training for trainers course in this area in the past year and a programme of training had been arranged in January 2006 for these staff. Eight staff had not received fire safety training but this was arranged for February 2006. There was evidence that new staff had completed an in-depth induction to the home and their role. An assessment of the nurse’s competency in the safe handling of medication was also completed as part of induction. Twelve of the twenty-four care assistants employed had achieved NVQ level 2 and 6 were training towards this. One staff member had completed NVQ 3 and one was training towards this. The staff and management should be commended for their commitment and achievements in this area. There were deficiencies in the recruitment process. Files for 5 staff who had been employed since the last inspection were examined. There was no evidence in files for two nurses that their professional Personal Identification Numbers (PIN) had been checked to verify their registration with the Nursing and Midwifery Council (NMC). In four cases Criminal Record (CRB) checks had not been received before employment although in three of these cases a POVA first check had been obtained. The manager was advised that where staff are required to be employed with a POVA first check before a full CRB check has been received she must contact the Commission first to discuss the each case and the staff member must be supervised at all times and records of this supervision must be maintained. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 21 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, 35, 36 and 38 An experienced manager runs the home although the registration process has to be completed. Service users money was safe guarded but current systems breach regulations. EVIDENCE: The manager Shirley Hannon has been in post since December 2005 prior to this she was the deputy manager at the home. Ms Hannon is a Registered Nurse and has many years experience in the care industry. Ms Hannon has previously been registered with the Commission as manager of a Nursing Agency. Ms Hannon is required to make an application to the Commission to be the Registered Manager of this home. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 22 The administrator maintains clear records where service users money is held by the home and receipts were held and there was evidence that the records were regularly audited. Service users money was paid into a single bank account and a small single cash float was held at the home, which service users could access. The bank account paid a low interest rate on the money held but the administrator was unable to state where the interest went which she stated was approximately 11 pence per month. Some of the service users records showed a negative balance and this meant that in the present system other service users were effectively loaning money without consent. The administrator stated that the systems were company procedures. The procedure of pooling service users money into a single bank account is in breach of Regulation 20, which states that ‘the home shall not pay money into an account unless the account is in the name of the service user or, any of the service users, to whom the money belongs’. There was evidence from staff and records that staff received regular supervision. There were some deficiencies in ensuring health and safety was maintained in the home. The manager had identified that not all the staff had received mandatory training and had implemented a training programme to address this. Oxygen cylinders were not secured in the storage area on the first floor despite equipment having been made available to do this. Fire extinguishers had been removed from wall hangers to prevent service users taking them off but they had been put in the shower room and behind the nurse’s station, which was not appropriate. Fire alarm tests had not been completed weekly between 29.9.05 and 1.12.05. Accident records were maintained but the records did not influence risk assessment or care practise. If this had been done the issue regarding incorrect seating would have been identified earlier and further falls would have been prevented. The manager was advised that in-depth analysis of accident records must be completed on a regular basis. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X 2 X X X 3 STAFFING Standard No Score 27 1 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 3 X 2 Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 24 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 OP15OP8O P7 Regulation 15 Requirement The registered person must ensure that the care plans reflect service users needs and health professional advice, risks are identified and risk management plans are developed. (Previous timescale 31 August 2005 not met) Dietry needs in relation to culteral or religious needs must be recorded The registered person must ensure that service users or their representative have agreed to their care and risk management plan. The registered person must ensure that there is adequate and appropriate equipment provided in the home to meet service users health and personal care needs. The registered person must ensure that oxygen cylinders are secured in storage areas. (Previous timescale – with imedaite efect- was not met) The registered person must ensure that accurate records for DS0000066375.V274386.R01.S.doc Timescale for action 01/03/06 2 OP7OP8 15 01/03/06 3 OP8 23(2)(n) 16(2)(c) 12/12/05 4 OP38OP9 13(2) 12/12/05 5 OP9 13(2) and 17 12/12/05 Randolph House Care Centre Version 5.1 Page 25 6 OP18 13(6) 7 OP22 13(4) 13(7) 16(2) 8 OP38OP19 23(4)(a) 9 OP27 18 10 OP29 19 medication are maintained. A bound book for recording receipt, administration and disposal of controlled drugs must be provided. Processes for receipt of drugs must be more robustly followed and staff to check that prescriptions provided match those recorded. Evidence must be provided that daily checks of medication fridge temperatures are being completed to ensure that the medication is being stored safely. The registered person must ensure that the Local Authoity POVA policies and procedures are obtained and implemented (Previous timescale – 31 July 2005 not met) and all staff have received training in this area. The registered person must ensure that service users who sit in specialist chairs that restrict mobility have been individually assessed for this equipment to ensure that this is the correct type of seating in the correct size. Evidence of assessment and agreement to the use of this equipment must be provided. (Previous timescale – 14 July 2005 not met) The registered person must ensure that fire extinguishers on Primrose unit are appropriately safely stored and ready to use. The registered person must ensure that the staffing levels in the home are sufficient to meet the needs of the service users and are consistently maintained. The registered person must ensure that registered Nurses PIN are verified with the NMC prior to employment. DS0000066375.V274386.R01.S.doc 01/03/06 01/03/06 12/12/05 12/12/05 12/12/05 Randolph House Care Centre Version 5.1 Page 26 11 OP29 19 12 OP35 20 The registered person must ensure all checks as listed in the requirement are obtained prior to employment of staff. (Previous timescale – with immediate effect- was not met) The registered person must ensure that service users money is only paid into a bank account, which is in the service users own name. Money must not be ‘lent’ by the home to a service user from another service users balance. The registered person must ensure that fire alarms are tested weekly. The registered person must ensure that accident records are subject to in-depth evaluation a regular basis. 12/12/05 01/02/06 13 14 OP38 OP38 23(4) 13(4) 12/12/05 01/02/06 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 OP11 Good Practice Recommendations The registered person should ensure that the service users guided includes service users views of the home, further information in relation to the manager and her experience and the responsible individuals name, qualifications and experience. Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Randolph House Care Centre DS0000066375.V274386.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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