CARE HOMES FOR OLDER PEOPLE
Rayner House 3-5 Damson Parkway Solihull B91 2PP Lead Inspector
Amanda Lyndon Announced 7 June 2005
th 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 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. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Rayner House Address 3-5 Damson Parkway Solihull West Midlands B91 2PP 0121 705 9293 0121 705 9011 zoecollis@raynerhouse.co.uk Rayner House and Yew Trees Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Zoe Collis Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number of places Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 10 February 2005 Brief Description of the Service: Rayner House is a purpose built care home, which provides residential care for 26 older people. The home, which is a Not For Profit Charitable Trust, is situated in the Damson Wood area of Solihull and is within close proximity to shops, bus stops, doctor’s surgery and a public house. Accommodation for service users is arranged on two floors which are serviced by a passenger lift, all bedrooms are for single occupancy and provide an en suite toilet and washbasin and are suitable for wheelchair users, with the exception of one bedroom. Rayner House has four bedrooms designated for short stay service users. Also provided are two lounges, a conservatory/activity room, a dining room and three bathrooms fitted with specialist baths and hoists. The home has its own hairdressing salon. The facilities and gardens are well maintained. The Rayner House “complex” also accommodates a day care facility and “Yew Trees” sheltered accommodation. Staff at Rayner House, have some responsibility for daily verbal communication with residents at Yew Trees. The day centre and sheltered accommodation were not inspected, as there is no requirement to register these facilities with the Commission for Social Care Inspection.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The announced inspection was undertaken by two Inspectors during a full day, and were assisted throughout by the Registered Manager. There were 24 residents living at the home on the day of the inspection and 4 of these people were receiving short stay care. Information was gathered from speaking with the residents, visitors and staff, observing the care staff perform their duties and examining care and medication records. Prior to the inspection 17 comment cards were received by CSCI about the service provided at Rayner House, and these were all found to be positive in nature. What the service does well:
Rayner House provides a homely, comfortable, clean and generally safe environment for residents to live in. Residents can personalise their bedrooms to reflect their individual tastes to ensure that they feel comfortable in their surroundings. Residents are able to exercise their choice over their daily lives and this promotes their independence and individuality and they can have a key to lock their bedroom door. One resident said “ We have a lot of freedom here, I couldn’t find another place as good as this”. Residents are well supported by the care staff to meet their health, welfare and personal care needs. Residents are offered a choice of homemade and wholesome meals and are encouraged to serve their own portions at mealtimes special diets are catered for. There is a comprehensive complaints procedure accessible to residents and visitors should they need to make a complaint. Staff receive appropriate training to ensure that they have the appropriate knowledge to work competently within their job roles. There is a wide variety of activities on offer for residents to participate in should they choose to. One resident said “ We had a lovely strawberry tea the other day and I sang all the time, it was very enjoyable”, and visitors are welcomed to the home. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 6 A robust system for the management of residents’ personal allowances is in place should the resident choose for the home to hold this on their behalf. What has improved since the last inspection? 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.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3 & 4 Residents receiving long stay care at Rayner House know before admission that the home can meet their care needs and they are issued with a contract to ensure that they are informed of the terms and conditions of their stay at the home. Prior to each admission assessments are not undertaken for all residents receiving short stay care and this has resulted in the home not meeting the needs of all short stay residents. EVIDENCE: The home had produced both a comprehensive Statement of Purpose and Service User Guide and these included all of the information as required by Regulations and were accessible to residents and other relevant people as required. Each resident is issued with a statement of terms and conditions of residency and this included detail of the room number to be occupied and fees payable. Pre admission assessments are completed by senior staff in respect of all prospective long stay residents using a comprehensive pre admission document.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 9 The home is registered for older people, however on the day of the inspection a small number of residents accommodated at Rayner House had dementia care needs and the senior staff must be mindful when assessing prospective residents, including those for respite care, that the home does not have a category for this. Residents receiving short stay care at the home are not reassessed prior to each admission to the home, therefore Rayner House are not always aware whether they can meet an individual’s care needs should their physical or mental health have deteriorated since the previous admission and this had resulted in a resident inappropriately coming to stay at Rayner House. The home could not meet this person’s care needs and this is unacceptable for both the individual concerned and the other residents living at the home. Letters are issued to prospective residents and/or their families confirming that Rayner House state that they are able to meet their needs prior to coming to live at the home and the home arrange for residents to be reassessed by Health Care Professionals should their care needs change. Residents appeared to be well supported by the care staff to meet their personal care needs. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Care plans did not always identify how the individual’s care needs can be met and this may have a negative impact on the delivery of care provided by the care staff. Further development is required to ensure that medication is always administered to the residents in a safe manner. Residents are supported in a respectful manner by the staff working at the home and this ensures that the residents’ dignity and self-esteem are maintained. EVIDENCE: Improvements had been made in respect of the care planning system at the home since the previous inspection and each resident had a separate set of care plans, however, this now required further development. Care plans were written and reviewed with the involvement of the resident and/or their representative and a number of these were individualised and included detail of the personal preferences of the residents, however these did not always give detail of the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of all of the residents are met. Care plans were not always reviewed on a monthly basis and a written
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 11 evaluation reflecting the current care needs of the residents were not always undertaken; care plan reviews were not always dated. Personal risk assessments had been undertaken however, nutritional, physical, mental health and pressure sore risk assessments did not describe the actual care to be afforded to residents. Moving and handling risk assessments did not include detail of the action to be taken should a resident fall and the size and type of sling and hoist to be used as required and not all of these had been updated to identify the resident’s current care needs and some of the daily reports described how residents had spent their day. Residents are weighed monthly and appropriate pressure relieving equipment is available as required and issued to residents following assessment. Residents have access to Health and Social Care Professionals, for example, Social Workers, Opticians, District Nurse, Speech and Language Therapists and Chiropodists. All residents were registered with the same General Practitioner who visits the home on a weekly basis as well as on request, however, residents can retain their own GP on admission to the home (if the GP is in agreement). It is recommended that separate records identifying input from Social and Healthcare Professionals and communication from relatives are devised for ease of monitoring the care provided for each resident living at the home. The home had produced a comprehensive medication policy and this included consent obtained from the residents’ General Practitioners in respect of homely remedies administered by the care staff and the procedures for those residents that choose to self administer their own medication. The home had purchased an appropriate storage cabinet for controlled medication and a storage cabinet for surplus medication. All prescriptions are checked by the care staff to ensure that the correct medication is being dispensed by the Pharmacy, and a record of these are kept at the home. All staff responsible for the administration of medication had received appropriate accredited training. Prescription creams were not signed for on administration and the actual amount of medication administered was not always recorded on the MAR chart for variable dosage medication. A system had not been implemented to ensure that the residents receive their medication when they go out from the home on social leave in a safe manner. A controlled drug had only been signed as administered by one member of staff and this was not signed as witnessed as per controlled medication administration guidelines. A weekly audit is undertaken however a written record of this was not kept.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 12 Staff were following the instructions of the relative of a resident receiving short stay care at the home and disguising their medication in their food and this is considered to be poor practice and inappropriate. As discussed earlier in this report the Registered Manager must ensure that Rayner House can meet the needs of all residents receiving care at the home and a Multi Disciplinary decision would need to be made in respect of all possible reasons for the covert administration of medication. A lockable storage facility was available in the majority of bedrooms however one of the residents that had chosen to self administer their own medication did not have this facility and a risk assessment had not been taken to determine this person’s ability to do this. Residents can request a key for their bedroom door and these can be overridden by staff in the event of an emergency, however a written record of the reasons why it would not be appropriate for named individual residents to have a key to their bedroom door was not kept. Rayner House has two private pay phone booths for residents’ use, however, the majority of residents have chosen to have a private telephone line in their bedrooms. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 13 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 standard(s) 12, 13, 14 & 15 Residents are able to exercise choice over their daily lives and the activities that they choose to participate in and this promotes their independence and individuality. The activities on offer meet the needs and expectations of the majority of the residents living at the home. Residents receive a wholesome and varied diet, which meets any special dietary needs. EVIDENCE: The home do not employ an activities organiser, however, there was a range of activities on offer for residents to participate in should they choose, including a ‘strawberry tea party’, barbeques, library books and shopping trips. The hair salon is open weekly and Holy Communion is available monthly. Activity plans had not been written and care plans did not always include detail of residents’ interests and activities that they may be interested in. One resident said “ I would like to be involved in more quizzes and bingo”. Another resident said “ We had a lovely strawberry tea the other day and I sang all the time, it was very enjoyable”. There is an open visiting policy at the home. One visitor said “ We always receive a warm welcome when we visit here”. Visitors can have a meal at the home.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 14 Residents go outside of the home with their families and friends as they wish. One staff member said “ If residents want to have a lie in they can and we help them to get out of bed at whatever time they choose”. One resident said “ We have a lot of freedom here, I couldn’t find another place as good as this”. The menus identified a wide range of appetising and wholesome home-made meals, two choices were available at lunchtime and a daily record of food eaten by each resident was kept. The home can cater for special dietary requirements, and it is recommended that the portions of pureed diet are served separately in keeping with good practice. In addition a hot drink and biscuit is offered mid evening. Appropriate feeding aids and adapted utensils were available for residents’ use as required following assessment. Residents were supported respectfully by the majority of care staff to serve their own vegetables and gravy at the dining tables to ensure that they had a choice about the portion sizes served and to maintain their independence, however it was noted that a care assistant was standing above a resident as she assisted her with her meal and this would be considered as being poor practice. The lunchtime meal was very relaxed and there was much social interaction between residents during their meal. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 15 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 standard(s) 16 & 18 The complaints procedure is comprehensive and is accessible to the residents and their visitors should they need to make a complaint. The home has produced a comprehensive adult protection procedure to follow should the needs arise. Senior staff training is required in respect of this to ensure that such incidents are recognisable and dealt with appropriately by the care staff. EVIDENCE: The home had produced a comprehensive complaints procedure and this included the contact details of CSCI. There were two complaints recorded in the complaints log since the previous inspection and one of these was made by a resident living at the home the complaint was resolved promptly to the satisfaction of the complainant. The home had produced a comprehensive adult protection procedure and this identified that Social Services are the lead agency in respect of this. Prior to this inspection an investigation had commenced following a complaint from a resident living at the home. Whilst the outcome of this is yet to be concluded, a senior staff training issue had been raised regarding the adult protection procedure to be followed by the person in charge of the shift in order to ensure that the needs of both the alleged victim and perpetrator are taken into account. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 Rayner House provides a homely, clean, comfortable and generally safe environment in which residents are relaxed and secure. The gardens are attractive and provide much interest for the residents living at the home. The facilities and equipment available at the home meet the needs of the residents living there. EVIDENCE: The internal environment of the home was decorated to a good standard and was homely in style. Furniture, fittings and floor coverings were of a good quality. There was a ramp access into the well-maintained external gardens and courtyard and it was pleasing to see that a number of residents were out enjoying their afternoon tea in the garden on the day of the inspection and this included people with limited mobility. There was adequate seating for all residents living at the home in the comfortable dining room.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 17 Adequate assisted bathing facilities were available and a walk in shower facility was due to be installed during the week following this inspection. Following assessment, residents could choose to bathe unsupervised and there was an emergency call system available in each bathroom. Handrails were available near toilets and raised toilet seats were available as required. Since the previous inspection the home have created an additional bedroom and all bedrooms met the minimum size requirements. All bedrooms had a call system in order for residents to summon the assistance of the care staff team as required. Bedrooms contained many personal items that reflected residents’ individual tastes to ensure that they were comfortable in their surroundings. The temperature within the home was found to be comfortable on the day of the inspection, radiators were of a low surface type, window restrictors had been fitted and lighting was adequate and domestic in style. Any hot water outlets that have a temperature above safe limits must be checked weekly until the problem is rectified. The home was found to be clean and fresh on the day of the inspection and hygienic hand washing facilities were available. Two mechanical commode pot disinfectors had been purchased and were being installed into the home for the staff to use to hygienically clean commode pots. An environmental health inspection had been undertaken recently and no requirements had been made during this. Contracts were in place for the disposal of clinical waste and any problems with pest control. Staff were manually sluicing soiled items of residents’ clothing and bed linen and this must cease with immediate effect as it may pose a risk to staffs’ health. Washing machines were available which had appropriate sluice wash cycles, therefore, an appropriate and hygienic procedure for the laundering of soiled items must be implemented. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Staff have undertaken appropriate training to improve their knowledge of caring for older people. During afternoons and weekends staffing levels did not meet minimum approved levels and this may pose a risk to residents’ welfare. An adequate procedure is in place for staff recruitment, but a lapse in this on one occasion fails to afford full protection to residents EVIDENCE: In addition to care staff, the home employs ancillary staff, namely kitchen, domestic, laundry staff and a maintenance person. Management staff provide on call support to the person in charge of the shift, however, the detail of this was not identified on the staffing rotas. Since the previous inspection there had been an increase in the number of care assistants on duty during the early shift from Monday to Friday, however, based on the information submitted to CSCI by Rayner House within the pre inspection information in respect of the dependencies of residents living at the home and the increase in occupancy at the home, this increase in the amount of staff on duty may need to extend to both early and late shifts each day of the week including weekends. The Registered Manager must undertake a full review of the staffing levels at the home. One resident said “ The staff are very helpful and if they can do anything to help you, they will”. Another resident said “ Sometimes staff are off sick and they are short staffed but they do their best”
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 19 Each member of staff had a staff file and two of these were sampled by the Inspectors. These contained all of the information as required by Regulations with the exception of a valid work related reference for one staff member and this may pose a risk to residents’ safety. Satisfactory criminal record checks were available. Staff had received training specific to the role that they perform including bereavement care, nutritional support, falls prevention and infection control. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 & 38 The Registered Manager has a good knowledge of working within her job role and ensures that a good standard of care is provided in the home. Robust procedures are in place for the regular monitoring of the standard of service provided at the home by external senior management. A robust system for the management of residents’ personal allowances is in place. Maintenance checks of equipment used at the home are undertaken, but attention to some health and safety issues as identified is required to remove risks to residents’ safety. EVIDENCE: The Registered Manager has had much experience of caring for older people and has the appropriate qualifications to perform well within her management role. One resident said “ The Manager is very good, I would go to her if I was unhappy about anything”.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 21 Regular visits to Rayner House are made by the Trustees of the home and a report of this is sent to CSCI as per Regulation 26, they ensure that a high standard of service is provided at the home. Plans were in place for residents meetings to be held on a regular basis and the minutes of these will be available in a large print format. A residents meeting had been held recently, however the minutes of this were not available. Quality of service satisfaction questionnaires are distributed to residents living at the home and an annual report based on the findings of these is produced and accessible to residents in the service user guide. The home do not manage the finances of residents living at the home, with the exception of holding personal allowances for safe keeping and a number of residents maintain their own benefit books. A robust system for the management of this was in place. The majority of staff had received their first formal supervision session and the system for annual staff appraisals was up to date. The missing persons policy had been amended and this included all relevant information. Comprehensive policies and procedures were tailored to meet the needs of Rayner House and these are reviewed regularly, however a number of these did not identify the new identity of The Commission for Social Care Inspection. The home inform CSCI of accidents involving residents living at the home as per Regulation 37 notifications. The cleaning trolley was left unattended in an area of the home that residents have access to and this stored COSHH products which may pose a risk to residents’ health and safety. A number of residents’ bedroom doors were held open with the use of door wedges and this would pose a risk to the safety of all people within the home in the event of a fire. The Registered Manager stated that plans are in place to fit magnetic closures to residents’ bedroom doors that are linked into the fire alarm system and risk assessments must be undertaken in respect of this until appropriate closures are fitted and other fire risk assessments had been reviewed recently. Health and safety maintenance checks had been undertaken on equipment used at the home including the portable electrical appliances, emergency lighting, gas appliances, fire fighting equipment and hoisting equipment.
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 22 Staff had received training in health and safety issues including fire safety training, basic food hygiene, moving and handling, first aid and a fire drill had been undertaken recently. One staff member said “ I have received a lot of training since I came to work here”. Accident records were found to be fully detailed and well maintained, however it is recommended that an accident log is devised for ease of auditing accidents involving residents living at the home. Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x 3 3 3 2 Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14 Requirement Pre admission assessments must be undertaken for all prospective residents receiving short stay care at the home prior to each admission. Timescale for action 8 June 2005 2. OP4 10 The Registered Manager received this in the form of an immediate requirement Individuals must not be accepted 8 June to stay at Rayner House who are 2005 outside of the homes category of registration. The Registered Manager received this in the form of an immediate requirement The care planning system must 7 September be further developed including: 2005 Care plans must detail the action which needs to be taken by care staff to ensure thst all aspects of the personal, health and social care needs of residents are met. They should include details of activities enjoyed by residents and how this need will be met Care plans must be reviewed monthly and a detailed 3. OP7 12(1)(a)( b) 15(1)(2) Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 25 evaluation must be undertaken and recorded and these must be dated. Personal risk assessments must describe the actual care to be afforded to residents and these must be reviewed monthly to reflect residents current care needs. Moving and handling risk assessments must include detail of the action to be taken should a resident fall and the size and type of sling and hoist as required. (time scales of 18 October 2004 and 10 May 2005 were not met) Daily reports must be recorded in detail and include information about the activities that the residents had engaged in during that day and the monitoring of residents acute care needs. (timescale of 10 April 2005 not met) Systems must be installed to ensure that the residents receive their medication when they go out from the home on social leave in a safe manner. Regular staff drug audits must be undertaken before and directly after a medication round to confirm the validity of the MAR charts and to assess staff competence in the safe handling of medicines. Appropriate action must be taken when discrepancies are found. (timescales of 24 February 2005 and 10 March 2005 were not met)
Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 26 4. OP7 12(1)(a)( b) 7 August 2005 5. OP9 13(2) 31 July 2005 Prescription creams must be signed for following administration. The actual amount of medication administered for variable dosage medications must be recorded on the medication charts. A risk assessment must be undertaken for any residents who self administer their own medication. The covert administration of 11 June medication must not be practised 2005 unless a multi agency decision has been made. The Registered Manager received this in the form of an immediate requirement 7 June The controlled drugs register 2005 must be signed and witnessed directly following administration and all discrepancies must be investigated and appropriate action taken. (timescale of 11 February 2005 not met) The Registered Manager received this in the form of an immediate requirement A lockable storage facility must 14 June be available for all residents that 2005 choose to self administer their own medication. The Registered Manager received this in the form of an immediate requirement Staff training must be 31 July undertaken in respect of adult 2005 protection procedures at the home
Version 1.30 Page 27 6. OP9 13(2) 7. OP9 13(2) 8. OP9 13(2) 9. OP18 13(6) Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc 10. 11. OP25 14(4) Any hot water outlets that have a temperature above safe limits must be checked weekly until the problem is rectified. An appropriate and hygienic procedure for the laundering of soiled items of residents clothing and bed linen must be implemented. The Registered Manager received this in the form of an immediate requirement The Registered Manager must undertake a full review of the staffing levels at the home based on the occupancy and dependencies of residents living there. Two satisfactory and appropriate references must be obtained for all prospective staff members prior to commencing employment at the home. The Registered Manager received this in the form of an immediate requirement 15. 16. 17. OP38 13(4)(a) All COSHH items must be stored securely at all times. (previous immediate requirement timescale of 10 February 2005 not met) 7 June 2005 01 July 2005 7 June 2005 12. OP26 16(2) (e) 13. OP27 18 31 July 2005 14. OP29 19(1) 8 June 2005 18. OP38 23(4)(a) The Registered Manager received this in the form of an immediate requirement Suitable magnetic closures must 14 June be fitted to residents’ bedroom 2005 doors that are linked into the fire alarm system and risk assessments must be undertaken in respect of this until appropriate closures are
Version 1.30 Page 28 Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc fitted. The Registered Manager received this in the form of an immediate requirement 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 OP7 Good Practice Recommendations It is recommended that separate records identifying input from Social and Healthcare Professionals and communication from relatives are devised for ease of monitoring the care provided for each resident living at the home. A written record of the reasons why it would not be appropriate for individual residents to have a key to their bedroom door should be kept. Staff should assist residents at mealtimes in a respectful manner. Staffing rotas should identify the senior staff member who is designated to provide on call support to the person in charge of the shift. Policies and procedures should identify the new identity of The Commission for Social Care Inspection. 2. 3. 4. 5. OP10 OP10 OP27 OP37 Rayner House E54_S4518_RaynerHse_V223410_070605 - Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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