Inspection on 04/09/06 for Redcot

This inspection was carried out on 4th September 2006.

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

The inspector 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

Redcot 25/10/05

Redcot 19/07/05

Redcot 11/01/05

Redcot 12/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Redcot Redcot Three Gates Lane Haslemere Surrey GU27 2LL Lead Inspector Denise Debieux Key Unannounced Inspection 4th September 2006 10:00 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 Redcot DS0000013756.V310848.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. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redcot Address Redcot Three Gates Lane Haslemere Surrey GU27 2LL 01428 644637 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) Friends of the Elderly Mrs Lorraine Miller Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Redcot is situated in a rural location a short distance from Haslemere town, which offers a good range of small shops a library and a museum. Redcot is a large detached property set in its own substantial grounds. There are limited parking facilities at the front and at the side of the building. Service users’ bedrooms are provided at ground, first and second floor levels and all have en-suite facilities. The home has a wide variety of communal spaces including outdoor areas to enjoy views across to the South Downs. The home has a terrace with plenty of seating and shade from the sun and very extensive landscaped gardens designed by Gertrude Jekyll. Fees range from £527 - £631.50 per week. This fee does not include newspapers, hairdressing, chiropody, transport, personal physiotherapy or arranged outings. This information was provided on 02/08/06. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 8.5 hours and was carried out by Denise Débieux, Regulation Inspector. Mrs Lorraine Miller (Registered Manager) was present as the representative for the establishment. A tour of the premises took place. Eight of the thirty-two service users and five on-duty staff were spoken with during the visit. In addition, eight service user survey forms and four care worker’s survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment records, health and safety check lists, menus, activity schedule, medication records and storage were all sampled. The lunchtime meal was observed and the home was toured. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? The ongoing maintenance, redecoration and refurbishment programme provides service users with a comfortable and homely environment in which to live. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Redcot DS0000013756.V310848.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 Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the service user’s identified needs. The home does not offer intermediate care. EVIDENCE: Three care plans were sampled during this visit. In each case pre-admission assessments had been carried out prior to admission to ensure that the home could meet the service users’ identified needs. Information was given to the manager in relation to a recent change to legislation regarding information to be included in the service users’ guide and the provision to service users of information regarding their fees. All service users surveyed confirmed they had received enough information prior to deciding to move into the home. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that all service users have an up to date, individual care plan that includes risk assessments and details the care required to fully meet all aspects of their health, personal and social care needs. Policies, procedures and practices are in place to ensure the safe administration of medication. Service users feel they are treated with respect and that their right to privacy is upheld. EVIDENCE: The care plans sampled during this visit were all based on pre-admission assessments and had been drawn up shortly after the service users’ admission to the home. The company has a comprehensive system of pre-printed care plans and risk assessments for the staff to use. In the service user files sampled there were separate, pre-printed care plans for each identified need. However, these care plans had not been individualised to the service user, actions to be taken had been left on the care Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 10 plans that did not apply and service users’ preferences in how they would like their care delivered had not always been added. Risk assessments had been carried out on admission but only where a risk had already been identified and are not carried out to assess potential risks (e.g. for the risk of falls; potential for skin breakdown). Also, the risk assessments are not reviewed regularly after admission to monitor changing risks as service users’ abilities or needs change. One service user was assessed as being at high risk of skin breakdown on admission but there was no follow up documentation to show what specific measures had been put in place to reduce the risks for this service user and no later review of the risk assessment. Another service user was identified at pre-admission as having a history of falls, no falls risk assessment had been carried out and the care plan relating to this risk had not been personalised to specifically include measures to reduce the risk of falls for this service user. There have been a substantial number of reported incidents of falls, slips and service users losing their balance. These incidents were discussed at some length during this visit. A visiting district nurse was able to provide the manager with the name of the local ‘falls’ nurse to contact for advice and guidance. Whilst it is recognised that these incidents cannot be totally prevented, the home must take steps to ensure that a system is put in place to evaluate and reduce the risk of falls where at all possible. All service users’ care plans must include risk assessments, particularly in relation to the potential risk of falls and skin breakdown. Risk assessments must be reviewed at least monthly and individualised preventative measures must be included in the care plans where risks are identified. The home has a policy that progress notes are made at least weekly for all service users, more often if there is a specific problem. This policy was seen to be followed. However, not all entries made by staff in the care plans had been dated and signed by the person making the entry. Service users are asked to sign a general statement that they have seen and agreed with their care plan. The inspector was told that this is renewed on a six monthly basis but this does not take into account the need for service users to agree any changes that may be made to their care plans in between signatures. Requirements and a recommendation have been made regarding care plans. Of the eight service users who returned comment cards, five answered that they always receive the care and support they need and three answered ‘usually’. The medication administration records, medication storage, policies and procedures were all sampled and found to be in order. The lunchtime Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 11 medication round was observed and seen to be in line with the home’s policies and procedures. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all personal care was provided behind closed doors. All interactions observed between staff and service users were seen to be caring and respectful. Of the eight service users who returned comment cards, four answered that their privacy is always respected and four answered ‘usually’. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provided by the home are varied, well planned, and include contact with the local community both within and outside the home, however, individual activity plans need to be developed as part of their care plan to ensure that all service users are able to partake in meaningful activities. Contacts with family and friends are encouraged. The meals in this home are good, offering both choice and variety and catering for special dietary needs. EVIDENCE: The home employs an activity co-ordinator, who started work in April of this year. Since then she has been working towards gradually developing the organised activities and events provided by the home. The activity schedule for August was seen at this visit and included quizzes, musical events, musical movement, film shows, flower arranging, shopping trips and outings, one of which was for a balloon flight. Of the eight service users who returned comment cards, three said there were always activities arranged that they felt they could take part in, three answered ‘usually’ and two answered ‘sometimes’. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 13 At present, the planned activity for that day is posted on the notice board, with upcoming outings being posted earlier. There are no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships inside and outside the home. Menus were sampled and seen to be varied and well-balanced. The lunchtime meal was taking place during the visit and the food was presented in an appetising manner. Ample staff were present and offered help or assistance where needed in a discreet and sensitive way. The atmosphere in the dining room on the day of this visit was convivial and unhurried. The home also provides a small dining area in one of the lounges, where service users are able to entertain friends and family in more privacy. Of the eight service users who returned comment cards, one said that they always liked the meals at the home, five answered ‘usually’ and two answered ‘sometimes’. Comments received included: ‘The quality and variety is excellent’ and ‘The standard varies’. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that service users and their relatives feel their views will be listened to. Policies are in place to protect service users from abuse but staff recruitment procedures and the need for more individual risk assessments are placing them at possible risk of harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives and is also included in the service users’ guide. At present the complaint’s procedure states that a complainant can contact CSCI if they are not happy with the outcome of any complaint to the home. A recommendation has been made that this be amended to advise people that they can contact CSCI at any stage of the procedure. Of the eight service users surveyed, all knew who to speak to if they were not happy. The home has a ‘Whistle Blowing’ policy in place and basic awareness of the protection of vulnerable adults is included in the home’s induction training. A copy of the latest ‘Surrey Multi-agency Procedure for the Protection of Vulnerable Adults’ is available in the manager’s office for staff to refer to. The home’s own policy has been amended and now indicates that staff will follow the local Surrey procedure. The manager and the deputy manager are booked to attend the Surrey local course in November of this year. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 15 All service users spoken with and surveyed told the inspector that they felt safe at the home. Staff recruitment is addressed in the ‘Staffing’ section of this report. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: Service users spoken with expressed their satisfaction with the accommodation provided at the home. Six of the eight service users surveyed stated that the home was always fresh and clean, with two answering ‘usually’. During the tour of the home the premises were seen to be well maintained with service users able to freely access all areas. All personal rooms seen were individualised to the service users’ wishes and were seen to contain personal items and mementos. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 17 On the day of inspection the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. The gardens are extensive and well kept, with many separate seating areas provided for the use of service users and their visitors in warmer weather. Laundry facilities are sited on the ground floor with washing machines appropriate for the needs of the service users at the home. A recommendation has been made that the home commission a qualified occupational therapist to carry out an environmental assessment of the home in relation to identifying any measures that can be taken to reduce the risk of falls and/or injury to service users. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing numbers meet service users’ needs. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times but the home needs to produce an action plan showing how the percentage of staff qualified to NVQ level 2 in care will be increased from 33 to 50 . Action must be taken to improve the staff recruitment procedures to ensure that the service users’ safety is protected and that all required information and checks have been obtained and verified for new employees before they commence employment. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. Of the eight service users surveyed, four stated that staff are always available when needed, three answered ‘usually’ and one answered ‘sometimes’. To date, of the fifteen care workers employed at the home, five have achieved National Vocational Qualification (NVQ) level 2 or above in care with one currently in progress. A requirement has been made that the home develop a clear plan, including timescales, setting out how the home will meet the minimum 50 of qualified carers. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 19 During this visit the files of four recently recruited members of staff were sampled. In these files, all had completed application forms, all contained two references, proof of identity and recent photographs. All had enhanced Criminal Record Bureau (CRB) certificates which included a check on the Protection of Vulnerable Adults (POVA) list. However, the names on two of these CRBs did not correspond with the names of the staff members and were therefore not valid. All application forms had gaps in employment that had not been explored or explained. The manager was unaware of the amendments to the regulations that came into effect in July 2004. These amendments were discussed with the manager and a copy of the new Schedule 2 was left for reference. A copy of the CSCI recent publication ‘Safe and sound?: Checking the suitability of new care staff in regulated social care services’ was also left at the home on this visit and requirements have been made. The home has an induction and ongoing training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). The training logs seen at this visit evidenced that all mandatory training and updates are provided promptly and the training records were well maintained and easy to follow. Additional training is provided that is relevant to the needs of the individual service users at the home. The inspector was advised that the company have recently developed a new training initiative, covering the provision of care to people with dementia. There is a one day course ‘stage 1 dementia training’ which all staff, including ancillary staff are required to attend. Service users spoken with were complimentary about the staff at the home. Of the eight service users surveyed, four stated that staff always listen and act on what they say, three answered ‘usually’ and one answered ‘sometimes’. One service user commented that ‘we do very well here’ and another that ‘they look after us well’. All interactions between the staff and the service users during this visit were seen to be caring and respectful. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Policies and procedures are in place to protect service users’ financial interests. All other policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The registered manager is a registered nurse and holds the Registered Manager’s Award. Mrs Miller has over thirty years experience working in the care field and has been the manager at Redcot for the past three years. There are residents’ meetings approximately every four months and an annual survey of service users and their relatives is carried out by an external agency. The inspector was advised that, when the results of this survey have been Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 21 correlated, a report is sent to the home and an action plan is developed to address any issues that are identified. A recommendation has been made that the home expand their quality assurance system to include seeking the views of stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). One comment was made on a survey form that ‘the degree of consultation with residents and the provision of information well in advance could be improved.’ A recommendation has been made that the home consult with service users to ascertain whether this is a generally held view and, if so, explore ways to improve the degree of consultation and the provision of information to service users. Staff surveyed all confirmed that they receive formal supervision and that group supervision is taking place in the form of staff meetings at least four times a year. A random sample of maintenance certificates and safety checks were seen at this visit. All were found to be well maintained and up to date. All interactions observed between the staff and service users were inclusive, caring and respectful. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP7.3 OP8.3 Regulation 13(4)(a-c) 13(6) 18(1) (c)(i) Requirement Timescale for action 04/12/06 2 OP7.3 3 OP7 The registered person must ensure that persons working at the care home receive training appropriate to the work they are to perform, with specific reference to any staff carrying out risk assessments. 13(4)(b-c) The registered person must 04/10/06 make arrangements to consult a suitably qualified person for advice regarding methods that can be put in place to reduce the risk of falls for individual service users at the home. (e.g. a nurse specialising in fall prevention.) 13(4)(b-c) The registered person must 04/01/07 14(2)(a) review all care plans and ensure (b) that each service user has an 15(1) individual plan of care that 15(2) includes the following: (a-d) • A comprehensive assessment 16(m)(n) of needs covering all areas of health, personal and social care (activity) needs; • Risk assessments, to include prevention of falls and risk of pressure sore development; • Details of all individual needs identified, including social care needs; DS0000013756.V310848.R01.S.doc Version 5.2 Redcot Page 24 • 4 OP28 18(1)(a) (c)(i) 5 OP29 19(1)(b) Schedule2 6 OP29 19(1)(b) Schedule2 Goal/objective for each need or identified potential risk; • Actions to be taken to ensure the goals are met and to include the service users’ preferences; • Report writing to evidence that identified needs and goals are being met; • Newly identified needs or problems must be promptly added to the care plan; • Signature of service user/representative to signify their involvement and agreement with the plan; • At least monthly reviews of care plan and risk assessments; • All entries made by staff to be dated and signed. The registered person must 04/11/06 develop a clear plan, including timescales, setting out how the home will increase the number of care assistants qualified to NVQ level 2 in care, to a minimum of 50 . The registered person must not 04/09/06 employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must 11/09/06 check all staff files and obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 DS0000013756.V310848.R01.S.doc Version 5.2 Page 25 Redcot 7 OP29 8 OP29 9 OP33.10 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for all staff employed since 26th July 2004. 18(2) The registered person must 04/09/06 (a-b) ensure that any staff that do not 19(1)(b) have all the required checks and Schedule2 documentation in place, are closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. 18(1) The registered person must 04/09/06 (c)(i) ensure that all staff responsible 19(1)(a-c) for staff recruitment are aware Schedule2 of, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. 11/10/06 24A(1-3) The registered person must submit, to the CSCI, Eashing office, an improvement plan, setting out exactly how requirements 1-8 will be met in full. The plan must set out the methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 26 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 OP7.3 OP22.1 2 OP7.3 Good Practice Recommendations It is recommended that the registered person arrange for a qualified occupational therapist to carry out an environmental assessment of the home in relation to identifying any measures that can be taken to reduce the risk of falls and/or injury to service users. It is recommended that the manager keep a log of all falls/injuries to establish whether there are any patterns (e.g. time of day) that could indicate action that can be taken to reduce the incidents. It is recommended that the complaint’s procedure be amended to state that a complainant can contact CSCI at any stage of the process. It is recommended that the home consult with service users to ascertain whether they are satisfied with the degree to which they are consulted about the services provided, as well as their satisfaction regarding the provision of information to them. It is recommended that the quality assurance system is expanded to include seeking the views of stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). 3 4 OP16.4 OP33.6 5 OP33.7 Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Redcot DS0000013756.V310848.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!