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Inspection on 05/12/05 for Redlands Acre

Also see our care home review for Redlands Acre for more information

This inspection was carried out on 5th December 2005.

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

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

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

What the care home does well

Redlands Acre provides a clean, well-maintained and comfortable home for the residents living there. The environment is safe, and retains a homely atmosphere. Residents are admitted to the home after an assessment of their individual needs and preferences has been undertaken by the staff, in order that they can be assured that the home will be able to provide the care they require. Residents are assured of their privacy when they want it, and staff demonstrated awareness and sensitivity towards the residents and their care. The staff themselves were very pleasant, welcoming and helpful, and showed an interest in the inspection process, and pride in their work. Residents spoken to during the inspection were very happy with the care they receive, saying that staff were very caring, kind and helpful, and that they are receptive to any concerns they may have. There are frequent opportunities for residents to participate in activities of a social nature, with a regular programme of entertainments, outings or events. Residents confirmed that they enjoy a good, home-cooked range of food, which can be offered according to their choice and preference. New staff undergo a structured induction training programme when they start at the home, and after that there continue to be very good opportunities for staff to access appropriate training for their role as an ongoing feature; this also includes access to the NVQ programme, with which the staff are making excellent progress. Some of the residents have chosen to place personal money with the home for safekeeping, and they can feel reassured by the home`s robust management and recording of each individual arrangement.

What has improved since the last inspection?

The home has done well to address a number of improvements that were required by the CSCI inspecting pharmacist, with the manager and staff effecting the necessary changes to the systems for managing medications; some corrective work has still to be carried out at this time however. Two care staff have attended a training course called `Active Ageing`, in order to enhance social and recreational fulfilment for the residents.

What the care home could do better:

Despite evidence confirming a good standard of care, there is room for improvement regarding the written planning and documentation of residents` care issues and needs. Some care plans inspected were not fully indicative of the care needed, and risk assessment work had not been carried out in full in some cases where such work was relevant. Recruitment of staff is in accordance with requirements in most regards, however some omissions in the procedure were identified on this occasion. Those responsible for recruitment must ensure that they adhere to the requirements regarding pre-employment checks at all times. The Registered Manager at Redlands Acre is long serving and has considerable experience in the home. However, she is giving consideration to her lack of formal management qualification, and will be submitting her proposals to the CSCI for consideration.

CARE HOMES FOR OLDER PEOPLE Redlands Acre 35 Tewkesbury Road Longford Gloucester Glos GL2 9BD Lead Inspector Mrs Ruth Wilcox Announced Inspection 5th December 2005 08:45 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 Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 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. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Redlands Acre Address 35 Tewkesbury Road Longford Gloucester Glos GL2 9BD 01452 507248 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) CTCH Ltd Mrs Ruth Hartland Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 September 2005 Brief Description of the Service: Redlands Acre is a care home providing personal care to 26 older people over the age of 65 years. Nursing care can be accessed from community resources if needed. The home is situated on a main route into Gloucester city, and is owned and managed by CTCH Ltd. The home has been converted from a large property, with the addition of some purpose built bedrooms on the ground floor. Access to the first floor is gained by the use of a staircase only; there is no stair or shaft lift in the home, though there are plans to install a platform lift in the future. However, the vast majority of bedrooms are situated in accessible locations on the ground floor. The home provides 26 rooms, 23 have en-suite facilities, which include a toilet and washbasin. The home provides an assisted bathing facility, and has a specifically designed shower room. The communal areas are situated on the ground floor and consist of two dining rooms, one of which has a small sitting area, 1 large lounge and a lounge/conservatory. The home also has another lounge, which is referred to as the ‘quiet room’. The conservatory connects the main house to the rear of the property where there are eight attached bungalows, which provide unregistered sheltered accommodation. Residents from this accommodation are welcomed into the life of the home on a daily basis, in terms of a meal and social activity. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection over six hours on one day in December. The Group Care Manager for CTCH Ltd, and the Registered Manager were present throughout the inspection providing assistance where requested. The home was warm and welcoming, and staff were most pleasant and helpful. The arrangements for assessing prospective residents before admission, and residents’ care records were inspected. The care of four residents was closely looked at in particular, and there was direct contact with twelve residents. Their views regarding the standards of services and care at the home were sought wherever practicable. Following the specialist inspection carried out in September 2005 by the CSCI Pharmacist, the management of medications in respect of the requirements issued for improvements were inspected to assess the home’s compliance. The opportunities for residents to have access to recreational activities and social fulfilment were looked at, and their options for meals, including the quality and quantity served was inspected. The management arrangements for the home were looked at, including the safeguards for those residents choosing to place personal valuables with the home for safekeeping. The policy and procedure for dealing with complaints was inspected. The provision of staff and the way in which they are recruited and trained was inspected. Staff were observed as they went about their duties, interacting with the residents, with eight members of staff interviewed. A tour of the premises took place, with particular attention to the standard of maintenance, health and safety and cleanliness. What the service does well: Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 6 Redlands Acre provides a clean, well-maintained and comfortable home for the residents living there. The environment is safe, and retains a homely atmosphere. Residents are admitted to the home after an assessment of their individual needs and preferences has been undertaken by the staff, in order that they can be assured that the home will be able to provide the care they require. Residents are assured of their privacy when they want it, and staff demonstrated awareness and sensitivity towards the residents and their care. The staff themselves were very pleasant, welcoming and helpful, and showed an interest in the inspection process, and pride in their work. Residents spoken to during the inspection were very happy with the care they receive, saying that staff were very caring, kind and helpful, and that they are receptive to any concerns they may have. There are frequent opportunities for residents to participate in activities of a social nature, with a regular programme of entertainments, outings or events. Residents confirmed that they enjoy a good, home-cooked range of food, which can be offered according to their choice and preference. New staff undergo a structured induction training programme when they start at the home, and after that there continue to be very good opportunities for staff to access appropriate training for their role as an ongoing feature; this also includes access to the NVQ programme, with which the staff are making excellent progress. Some of the residents have chosen to place personal money with the home for safekeeping, and they can feel reassured by the home’s robust management and recording of each individual arrangement. What has improved since the last inspection? The home has done well to address a number of improvements that were required by the CSCI inspecting pharmacist, with the manager and staff effecting the necessary changes to the systems for managing medications; some corrective work has still to be carried out at this time however. Two care staff have attended a training course called ‘Active Ageing’, in order to enhance social and recreational fulfilment for the residents. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 7 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. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 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 Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 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): 3. All residents are admitted to the home on the basis of a full assessment of their needs, ensuring that they can receive the care that they require. EVIDENCE: Assessments for prospective residents are performed by the home, prior to admission. The pre-admission assessment for a recently admitted resident was inspected, and was adequately recorded. During case tracking, this resident said that she was slowly settling, and that staff were supporting her since she had been in the home. Redlands Acre does not provide intermediate care. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 & 10. There is a care planning system in place, which in the main adequately provides staff with the information they need to satisfactorily meet residents’ health and personal needs; omissions in recording have not compromised residents’ health needs being met at this time, though improved recording in some cases would be more representative of how health needs are being met in practice. The systems for the management and administration of medications are being improved for the safety of those living and working in the home. Personal support in this home is offered in such a way as to promote the residents’ privacy and dignity. EVIDENCE: Each resident has an individual plan of care, which is based on an assessment of all their needs, including risk assessments. Four were selected as part of the case tracking exercise, and parts of these were satisfactorily written, were done so in consultation with the resident concerned, and were regularly reviewed. There were some omissions however in the documentation, as follows: Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 11 Falls risk assessments, though addressed in part for those to whom this was applicable, were incomplete • One person, who evidently had some mental health needs, had no plan of care to address this. However, the Community Psychiatric Nurse (CPN) had been consulted, and on case tracking staff demonstrated awareness of the resident’s condition and needs • There was no recorded outcome of the CPN’s interventions • A physiotherapist had previously seen the same resident, when a decision to continue with ‘exercises’ had been made; the care plan was not reflective of this in any way. Residents’ records showed that all access to health care services for their needs is ensured by the home, with records of General Practitioner visits, Continence Nurse assessments, Chiropodist visits, Community Nurse visits, seen. There was also evidence that the Falls Prevention Officer is consulted when appropriate. Care Programme Approach documents had not been sought for those receiving input from the psychiatric services. The home intends to introduce a new care planning system in the near future, for which staff will receive additional training. The home has made very good progress towards achieving compliance with the statutory requirements issued as a consequence of the recent specialist pharmacy inspection. Additional and updated Royal Pharmaceutical guidelines and drug reference book have been supplied, with improvements to medication storage completed, planned or underway. Aspects of medication recording have also been improved. Residents spoken to confirmed good levels of satisfaction with their care, with some saying that staff are respectful towards them and their privacy. Care plan recording is reflective of individual’s privacy and dignity, and staff themselves were observed to be respectful, mindful and sensitive to residents as individuals. • Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 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 & 15. An activities and entertainments programme is offered, in order that residents are provided with regular and varied opportunities for social activity. Dietary needs of residents are adequately catered for, with a selection of food available that meets their tastes and choices. EVIDENCE: A monthly diary of social events is issued to all residents. These programmes show a range of social opportunities, which vary from exercise sessions, to quizzes, bingo and other games, to parties and social gatherings and outings. Two staff have recently attended specific training in this area, provided by the Primary Care Trust and called ‘Active Ageing’. This programme focuses on physical and mental stimulation for residents, and has increased the opportunities for consultation with the residents themselves. Staff spoke enthusiastically about this new introduction into the home. Some of the residents themselves confirmed that they pursue their personal interests in terms of recreation, and some were seen going out, reading their newspaper, listening to music, doing crosswords or just socialising. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 13 There is a range of varied and nutritious meals available for residents, and from conversations and observation of the lunch it was clear that they are also offered choice with their meals. Residents are consulted a day in advance regarding their choices from the menu, with a list of preferences sent to the kitchen for the cook’s reference, with special diets observed. The meal looked wholesome and appetising, and residents confirmed their enjoyment of it. The meal was nicely presented, with gravy boats, condiments and drinks provided. All residents spoke positively about the quality and quantity of food provided for them, saying that the food was good and home cooked. The kitchen has recently been inspected by the Environmental Health Inspector, so was not visited at this inspection. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 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. The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. EVIDENCE: A copy of the complaints procedure was clearly displayed for anyone wishing to read or use it. Residents confirmed that staff were attentive to them, with some saying that staff are receptive to any concerns, and will do anything they can to help them. Staff also indicated that they are eager to address any concerns as soon as possible. The home maintains a record of any complaints and concerns received. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 15 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 & 26. The environment within Redlands Acre is satisfactorily maintained and decorated, providing residents with a comfortable and clean place in which to live. EVIDENCE: Redlands Acre was very warm and welcoming on the day of this inspection. All areas are homely and comfortable, and are well maintained. A window frame in an upstairs bedroom was noted to be in a poor state of decoration, but this was reported to be prioritised for maintenance attention. Maintenance records are kept, with staff able to identify any areas of concern on a list of maintenance issues requiring attention. The installation of a platform lift is planned for the near future, which will provide easier access to the first floor from the ground. A recent health and safety inspection identified no concerns in the environment. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 16 The home is cleaned to a good standard, with all areas fresh and odour free. The laundry room has infection control procedures displayed. There are no hand washing facilities in here, and staff use an alcohol based hand-gel cleanser. The washing machine in the laundry is only able to wash laundry up to 60°C instead of the 65°C required to disinfect any foul items. The home reports that in the event this type of laundry is produced, it is appropriately bagged and secured, and sent to a ‘sister’ home with the necessary disinfection facilities. There are plans to replace this washing machine at the earliest opportunity. Clinical waste is handled appropriately, and gloves and aprons are provided for the staff. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 17 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 & 30. Staffing provision is adequate to meet the needs of the residents currently living in the home. The home has appropriate recruitment procedures for the protection of residents, however any failure to observe these consistently could pose some risks to them. The arrangements for the induction and training of staff are good, with the staff able to demonstrate an understanding of their roles. EVIDENCE: Staff rotas are recorded, and these plan for three carers to be on duty during all day time hours; one waking and one sleep-in carer work overnight. In addition to this, the Registered Manager works in a supernumerary capacity on five days of the week, and a fourth carer works during the morning on three days of the week, providing some support to residents, but also helping with domestic tasks. There are no designated laundry staff, with care staff performing these duties. There is a housekeeper on duty on six days of the week to clean the home. A cook is on duty each day, and there is a peripatetic maintenance person. No-one under the age of 21 years is left in charge of the home. The manager performs periodic dependency audits, as a means of monitoring the staff provision in terms of meeting the needs of the residents most appropriately and efficiently. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 18 Staff on duty were observed, and were spoken to. They appeared to be a cohesive team, who were very aware of their individual roles and responsibilities, and who were sensitive to the residents’ needs. Residents themselves spoke very positively about the staff team, saying that they were very kind, helpful and caring. Three staff files were selected for inspection on the basis of recent recruitment. Much of the recruitment procedure had been carried out satisfactorily, however there were a number of omissions, as follows: • A portable CRB disclosure from previous employment had been used in the case of a Cook. This disclosure was over one year old, and was inappropriate, not only in terms of time, but because it meant that a POVA check had not been carried out • In another case, only a very sparse employment history had been received with evidently very little employment having been held. In consideration of this, there was no evidence that written reasons for employment gaps had been sought, or that they had been explored; the manager did say that that she had asked about it at interview however. In the absence of interview notes in this case, it was not possible to see direct evidence of this • In another case the person had evidently worked with vulnerable adults in a previous position; this did not feature in the employment history however • There were no photographs of the workers on their files. New staff receive a structured induction training within the first six weeks of employment with additional in-house training more specific to Redlands Acre, and a nominated supervisor with whom they must work during this period. Training records showed that staff progress to the foundation training course before going on to the NVQ programme, plus have access to a range of other mandatory and optional training appropriate to their roles. Staff themselves spoke very positively about the many training opportunities available to them. The home has made excellent progress with NVQ training, with eight care staff currently qualified, three of whom are qualified to level 3 standard. In addition to this, there are four others currently working towards the NVQ 2 award. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 19 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 & 38. There are good management systems in place to ensure that the interests, health and safety of the residents are safeguarded. EVIDENCE: The current manager has had a very long serving career at Redlands Acre. She is registered with the CSCI, but has not undertaken any management qualification to date. The manager has attended a variety of study days to ensure some professional development. The manager has decided on a planned retirement date, though this is not in the immediate future. Further to a query from the CSCI, she has been considering options to obtain a management qualification. A course has been sourced through a training provider, though it is not anticipated that this course will be assessed as an ‘equivalent’ qualification to that which the CSCI expects. However, the course content is to be sent to the CSCI for consideration as soon as possible following this inspection. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 20 Some residents have placed personal money with the home for safekeeping. Thorough records for each person, which include transaction details, running totals, and receipts, are kept. Two random checks proved to be accurate. Residents or their representative can sign to acknowledge transactions, but where this has not been possible in the majority of cases, two staff members sign the record to witness on behalf of the resident. Residents have signed to acknowledge the receipt of their personal allowances. A Health and Safety Executive inspection has been carried out earlier this year, and the report from this showed that good standards were noted in the home. There is evidence that health and safety issues are addressed satisfactorily in many areas, with written policies, procedures and risk assessments, provision of necessary equipment and staff training. Safety checks and maintenance of equipment had been undertaken in a timely fashion, though there was no evidence to confirm that the boilers had been serviced recently or that it had been carried out by a CORGI registered engineer; the Group Care Manager agreed to send evidence of this through to the CSCI immediately after this inspection. All staff have received one day’s ‘Appointed Person’s’ First Aid training. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 21 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 22 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 2 Standard OP7 OP7 Regulation 13(4c) 15(1) Requirement Staff must complete falls risk assessments in full in all cases where they are applicable. Staff must ensure that care plans clearly detail how each individual need regarding the health and welfare of the resident is going to be met. (This is with particular reference to those with mental health needs on this occasion) (Previous timescale of 31/8/05 not met) Staff must devise a care plan that clearly identifies how residents’ needs are to be met following interventions by the physiotherapist. Staff must record any nursing provided by a CPN, the resident’s condition and any treatment given. The registered person must obtain a new CRB disclosure and POVA check in the case of the identified worker, and advise the CSCI when completed. As part of the recruitment procedure, the registered person DS0000016555.V250116.R01.S.doc Timescale for action 31/01/06 31/01/06 3 OP7 15(1) 31/01/06 4 OP7 17(1a) Sch 3(3k) 19. Sch 2 31/01/06 5 OP29 31/01/06 6 OP29 19. Sch 2 31/01/06 Redlands Acre Version 5.0 Page 23 must obtain the following in all cases: • Full employment history with satisfactory written explanation of reasons for gaps in employment A photograph of each worker. • 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 The registered person should obtain a copy of the CPA from the psychiatric services, in cases where this may apply. Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Redlands Acre DS0000016555.V250116.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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