Inspection on 21/09/06 for Rheola

This inspection was carried out on 21st 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rheola 22/08/07

Rheola 29/11/05

Rheola 25/05/05

Rheola 14/12/04

Rheola 20/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Rheola Broad Leas St Ives Cambridgeshire PE27 5PU Lead Inspector Nicky Hone Key Unannounced Inspection 12:15 21 September 2006 and 18th December 2006 st 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 Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rheola Address Broad Leas St Ives Cambridgeshire PE27 5PU 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) 01480 375163 01480 375160 Rheola Healthcare Ltd Jeanetta McNally Care Home 42 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (32) of places Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate up to 32 people in the category OP & up to 13 people in the category DE(E) 29th November 2005 Date of last inspection Brief Description of the Service: Rheola is a care home registered to provide for a total of 42 elderly people including 13 people with Dementia related care needs. Originally a Local Authority care home it was acquired by Excelcare Holdings in 2001. The home is situated a few minutes walk from St Ives town centre. It is a large house that has been converted to a care home and has had an extension added to the rear of the building. There are well kept gardens to the rear and side of the property. The home is divided into four units Rose, Thistle, Shamrock and Daffodil. Each suite has a separate dining room, lounge, kitchen, toilets and bathroom. Rose suite is a single storey extension that provides accommodation for 10 people who have extra care needs related to dementia. Thistle and Shamrock suite each have 12 bedrooms whilst Daffodil suite has 8 bedrooms. Each bedroom has a washbasin. Twelve rooms have full ensuite facilities. The home has a contractual agreement with Huntingdon Primary Care Trust to provide 6 respite care beds and has recently agreed with the PCT to provide up to 3 Intermediate Care beds. Fees for the services offered at Rheola range from £351 to £500 per week. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days, with the majority of the inspection taking place on the first day. Both visits were unannounced. In total, the inspector spent over seven hours in the home, speaking with service users, staff and the manager, looking at records and making a tour of the building. The inspector discussed the findings on the first day with the manager and the Regional Operations Manager (ROM) of Excelcare, and with the manager on the second day. A few days before the first visit, an anonymous complaint was received. This raised concerns around a number of areas to do with different aspects of the service being provided at Rheola and was discussed during the feedback session. By the second day of the inspection, the ROM had written to the CSCI to say she had investigated the complaint and found all the issues raised to be unsubstantiated, other than issues to do with the cleanliness of the home. The allegations regarding cleanliness were found to be true and the ROM wrote that the manager has reviewed cleaning schedules to ensure that all parts of the home are kept clean. What the service does well: The manager, Jeannetta McNally, has worked at the home for a long time. She spent several years as deputy manager, before being registered as the manager approximately two years ago. She is well liked by staff and service users. Interaction between staff and service users was observed to be warm, friendly, caring and respectful, and service users spoken to said that generally “the staff are lovely”. Visitors are welcomed at the home at any time, if service users want to see them, and the majority of people spoken to said that most of the food is tasty, well cooked and well presented. The entrance to the home is welcoming and staff are very friendly and courteous to visitors. The home has a complaints procedure and complaints are dealt with properly. Staff are clear about Protection of Vulnerable Adults, what abuse means, and how to recognise and report abuse so that service users are kept safe. Staff meetings take place regularly and staff receive regular supervision. Recruitment procedures are thorough, with all the required information about staff being obtained before the person starts to work at the home, and records seen are maintained as required. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: It is disappointing that this inspection has resulted in seventeen requirements being made. It is not clear whether the PCT (Primary Care Trust) is purchasing an Intermediate Care (IC) service from the home, but it is clear that the intensive rehabilitation, which should be part of an IC service, is not being offered. The home must ensure its statement of purpose and service user guide detail the service that is being offered. Care plans are in place for all the service users, but do not always give sufficient detail for staff to be sure they are meeting each individual service user’s needs, and in one unit were not stored securely so service users’ confidentiality and privacy might not be maintained. Records do not clearly show that service users’ healthcare needs are met. Medicines are not administered or stored properly. All the service users spoken with said they are bored because there is not enough to do. On the first day of the inspection the post of activities coordinator was vacant and staff said they do not have time to do activities with the residents. An activities coordinator had been appointed by the second day: records seen showed that activities are improving but this will be checked more thoroughly at the next inspection. Some areas of the home were very dirty, including communal toilets, bathrooms and the main kitchen, and there was a strong smell of urine in parts of one of the units. Staff and service users spoken with said they feel there are not enough staff on duty to meet the needs of the service users, and records showed that staff have not received adequate training to be able to do their jobs well. This includes training in health and safety related topics such as manual handling, food hygiene, infection control, first aid and fire safety. There were some hazards to service users’ safety noted around the building, and in the grounds. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Full assessments of each person’s needs are carried out so the home is sure it can meet those needs. However, the arrangements to deliver short term intensive rehabilitation that an Intermediate Care service should offer are not satisfactory. EVIDENCE: The files of two service users were checked. These both contained a full Care Management assessment of the person’s needs which had been carried out by a Care Manager/Social Worker before the person was admitted to the home. The home always carry out their own assessment of the person’s needs by visiting them, at their home or in hospital, before admission. Occasionally, if the person lived a long distance away, a manager from another Excelcare home would be asked to carry out this assessment. However, following some difficulty recently with a service user whose needs had been fully assessed, but Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 10 not by staff from Rheola, the manager now makes sure that someone who knows Rheola well carries out the home’s assessment for each new person. Intermediate care is a special service arranged at some homes by the local Primary Care Trust (PCT). It is for people who need some intensive rehabilitation to enable them to return to their own homes. It is usually limited to a six-week period for each person, sometimes followed by a second six-week period if the team thinks that further improvement is possible. There appears to be some confusion about whether there is an Intermediate care service offered at Rheola. The inspector was told that there are three places purchased by the PCT for Intermediate care. The manager said that personal care and promoting the person’s independence is offered by Rheola’s own staff, and they are supported by the Intermediate Care (IC) team. The home does not have a written policy on Intermediate care and there is no written agreement as to what support the IC team will give the home. In practice, this does not seem to include much, if any, rehabilitation. At this inspection all three places were occupied. Two of the people using these places had been at the home for three months and were both waiting for a permanent place at Rheola. The third person had only been at the home for a few days and was far too poorly to be at Rheola. An urgent request had been made for a place in a nursing home to be found. On one person’s assessment notes from the hospital it appeared that the service being requested was for Interim care, not Intermediate care. (Interim care is care offered as an alternative to hospital whilst the person waits for a place in a care home, and does not necessarily include any rehabilitation in the same way as Intermediate care should). The manager must clarify the position about Intermediate care because at the moment the home does meet the National Minimum Standard regarding Intermediate care. She must also ensure that the home’s Statement of Purpose and Service User Guide give a true reflection of the services offered by the home. The home must operate within its statement of purpose, and people must not be misled into believing they are to receive a service which is then not given. A copy of the revised statement of purpose and service user guide must be sent to the CSCI. The requirement made at the last inspection, that care plans must include information relating to service user’s Intermediate Care aims where applicable, has not been met. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements for the administration and storage of medication are not robust enough to ensure service users are kept safe. EVIDENCE: Records for two service users were looked at and there was a care plan on the file for each of them, with evidence that these are reviewed monthly. Currently any changes to the plan are recorded on the review sheet. The manager might consider whether it would be more appropriate to change the plan itself. Although the care plans give reasonably good information to staff, there is still some further detail that could be improved. For example, on one person’s plan it had been recorded “likes activities”, but there was no further detail about which activities this person is interested in. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 12 The care plan for a second person, who lives in the unit for people with dementia care needs, states that the person can be kept occupied by being taken for a walk, or having knitting wool to wind. Neither activity was offered on the day of the inspection. One service user said there are no showers at Rheola so she has to ask to have a bath, and only gets one once a week or once a fortnight. There was some evidence on the files that healthcare needs, such as treatment by district nurses, optician, dentist, chiropodist and so on is carried out when required. But records seen were not adequate to show clearly that healthcare needs have been addressed. For example, on one person’s file it was noted that this person had seen the chiropodist in 22/10/04 but not since, yet the manager said the chiropodist treats this person’s feet every six weeks. It was not clear whether staff have received training in the administration of medicines from an external source qualified to give this training. Staff told the inspector that medication is now administered by two staff, to stop mistakes being made. However, there were gaps in the records of the administration of medication (MAR charts) seen on Rose suite, so it was not clear whether a medication had been given or not. A change to the administration instructions on the MAR chart for one person were muddled and had not been signed. There appeared to be no clear policy that keys to the drug cupboards must be kept on the person of whichever staff member is in charge. Staff said that keys were either hanging in the kitchen, in a cutlery drawer or in the office. One medication trolley was in a lounge area and was not secured to the wall. Although there was a sheet at the front of the MAR charts file to identify the initials of each staff member, there were initials on the chart of someone whose name was not on the list, and a member of staff told us her name was not on the list. Most service users said that staff respect their privacy; one person said that staff are getting better at remembering to knock and then wait to be invited into the room, rather than just knocking then walking in. Care plans in one unit were in an unlocked cupboard so were easily accessible to anyone, meaning that information about individual service users was not kept confidential. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Visitors are welcomed and meals are good, but there is little for service users to do to stop them being bored. EVIDENCE: On the first day of the inspection, several service users spoken with said that they are bored and the days are very long. They said there is nothing to do, no outings and nothing happens in the home except the occasional game of bingo. One service user said “everyone sits all day as there’s nothing to do”. Another explained that there is no activities coordinator in the home at present, so even bingo has not taken place for ages. A church service takes place weekly in one of the lounges. The manager said that a person had been appointed to the post of activities coordinator. This person had started work by the second day of the inspection: a record of activities in one person’s file indicated that the number of activities being offered is improving: this will be checked more thoroughly at the next inspection. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 14 Family and friends are welcome at the home at any time, and service users can choose whether to meet them in the communal areas of the home, or in their bedroom. Residents meetings are held monthly and minutes taken, although service users spoken with were not sure whether the meetings are very effective. One person said “they write down what we say”, and another said “our views aren’t always taken up”. One person spoken with said the food is not too bad at all, there’s enough to go round and it’s pleasantly served. Other people said that the cook is excellent and they are offered a choice of the main course at lunchtime every day. They said that choice for tea was not so good: cheese sandwiches or jam sandwiches most days. Another said that the menu on the wall was typed in a print that is too small for most people to read. One person said that the meal on the menu was not what had been produced for lunch, and s/he does not enjoy the food. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 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 the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and concerns are investigated. EVIDENCE: The home has a complaints procedure in place and complaints are investigated. An anonymous complaint had been received by the CSCI a few days before this inspection. The letter raised concerns about several areas of the service offered by Excelcare, particularly at Rheola. The content of the letter was discussed with the manager and Regional Operations Manager (ROM) during the inspection. An investigation was undertaken by the Rom and a response sent to the CSCI f a few days after the inspection. Apart from the cleanliness of the building, all the other allegations were found to be not true. (See the section on Environment in this report). All except three staff have received training in Protection of Vulnerable Adults (POVA). Staff spoken with were clear about the meaning of abuse and what to do if they suspect a service user is being abused in any way. The home has a policy and procedure on POVA in line with Cambridgeshire County Council’s protocol. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 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, 20, 24, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The standard of cleanliness and maintenance of the environment in some areas of the home is poor so that service users do not have a clean, comfortable and well maintained place to live. EVIDENCE: It was very disappointing that during the inspection there was evidence in several areas of the home that the standard of cleaning and maintenance was poor. For example, there were thick cobwebs in several rooms and in the corridor; some window frames and window sills were dirty; a commode was filthy and the fabric damaged; curtains were coming off rails; the floor in a toilet was stained; the bin in a toilet was covered in faeces; a bedside table was stained; walls and door handles were dirty; there were holes in plaster walls and patches of wallpaper missing; and one bath was filthy. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 17 Some of the bed-linen seen was grubby, pillows were lumpy and towels frayed. Linen in the linen cupboard all looked grey, and some of it was stored on the floor. In several of the service users’ bedrooms there were notices to staff about disposal of incontinence pads, and in almost every bedroom seen there were tatty notices about risk assessments. Staff must remember that these are service users’ rooms, and this is their home: if notices to staff are needed they should be in staff areas only. The manager had started to make a list of bed-linen and towels that needed to be ordered. One of the garden areas was untidy and there was a lot of rubbish (for example old doors, baths, chairs, a trolley and so on) in the garden outside Rose suite. The main kitchen was very dirty in all areas, including the floor, the bin, the fridge and freezer doors, the store cupboard, the trolleys, the tables and so on. There was a strong smell of urine in the corridor and in one of the bedrooms in Rose suite. One bedroom which smelt of urine on the first tour of the home had been successfully cleaned when the inspector returned. The anonymous complaint received just before the inspection had alleged that the home was not clean. This was discussed with the manager who accompanied the inspector on a second tour of the home so that some of the failings could be pointed out. This part of the complaint was substantiated, both by the inspector and by the ROM who investigated the complaint. One of the service users who spoke with the inspector said, “the cleaning could be a lot better”. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are not always sufficient staff on duty to meet the needs of the service users. EVIDENCE: One service user said “there are some lovely staff”, and another “they’re all very nice”. Two people in one of the units said there are not enough staff for them to be able to spend time with the service users, “they’re always running about”, but “they’re kind to us and do what they can”. Staff spoken with said they enjoy working at the home and it is a good staff team who support each other and cover shifts for each other. However they also said that more staff are needed so that they can give the quality of care to the service users that they want to give. They said that since the activities coordinator left there has been no time for many activities for the service users. A staff meeting took place on the day of the inspection. Staff meetings are held monthly and minutes taken. The record of staff training shows that the majority of staff have received training in a number of topics. All except three staff have been trained in Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 19 Protection of Vulnerable Adults, most staff have done manual handling and food hygiene training and fourteen staff have undertaken training in care of people with dementia. One staff member said she has started her NVQ2 in care. However, only the manager, senior team leader and four night staff have been trained in first aid, and no staff have had training in infection control. There was a discrepancy in the record of training in fire safety: the training matrix showed that four staff had fire safety training in July 2006, but records in the fire log showed the last fire training as 31/01/06, undertaken by fourteen staff. The home has a good recruitment policy. One staff personnel file was looked at and all the documents required, including evidence that a Criminal Records Bureau check has been done, and references received, were in the file. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 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, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Matters to do with health and safety are not given high enough priority to be sure that service users are kept safe. EVIDENCE: The manager, Jeannetta McNally has worked at Rheola for many years and knows her job well. She is planning to undertake the Registered Manager Award (NVQ4). The quality assurance system includes questionnaires being sent to relatives from head office. The results are collated into a report, along with results from the other Excelcare homes in the area, and the report is available in the home Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 21 and sent to the CSCI. Meetings are held regularly for service users to express their views, however a couple of people spoken with were not convinced any action is taken. The home does not keep money for any of the service users, therefore this standard is not applicable. Occasionally a relative will leave money for the hairdresser in the office: the manager said a receipt is issued. Records of staff supervision showed that all staff receive regular supervision from one of the four people who make up the management team of the home. Records of tests of fire equipment show that tests have been carried out as required. The inspector had some concerns about health and safety in the home. Some of the wardrobes had not been secured to the wall so there was a risk they could topple forwards; the door to the laundry room was propped open; the door to the main kitchen did not shut properly; and food in the fridge in the main kitchen had not been labelled with the date it was put in the fridge. The unclean state of parts of the home, especially communal toilets, bathrooms and the main kitchen could be a risk to service users’ health. A number of staff have not received training in topics related to health and safety (see the Staffing section of this report) Rheola DS0000015108.V293499.R01.S.doc Version 5.1 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 2 X 3 X X 1 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 1 X X X 2 X 1 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A 3 3 2 Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 and 5 Requirement The home must operate within its statement of purpose and service user’s guide. A copy of the up to date versions of these must be sent to the CSCI within the timescale. Each person must have a service user plan (care plan) giving staff sufficient detailed information for them to be able to meet the needs of each service user. Care Plans must include information relating to service user’s Intermediate Care aims where applicable. This requirement is carried forward as the timescale of 01/01/06 was not met. Timescale for action 31/01/07 2 OP7 15(1) 31/01/07 3 OP7 15(1) 31/01/07 4 OP8 13(1)(b), 17(1)(a) and schedule 3 13(2) and 17(1)(a) Records must show that service 31/01/07 users have received, where necessary, treatment, advice and other services from healthcare professionals. The registered person must ensure that records of the prescribing and administration (or non-administration) of DS0000015108.V293499.R01.S.doc 5 OP9 21/09/06 Rheola Version 5.1 Page 24 6 OP9 13(6) and 18(1) 7 OP9 13(2) 8 9 10 11 OP9 OP10 OP12 OP19 13(2) 12(4)(a) and 17(1)(b) 16(m) and (n) 23(2)(b) and (d) 12 OP19 23(2)(o) 13 14 OP26 OP27 16(2)(k) 18(1)(a) 15 OP30 18(1)(c) medicines are accurate and complete. The registered person must ensure that all staff authorised to administer medicines have been trained and assessed as competent to do so. Keys to medicine storage areas (cupboards, trolleys and so on) must be kept securely on the person of the member of staff in charge. Medicines must be stored safely. Medication trolleys must be secure. Care plans must be kept securely to preserve service users’ right to confidentiality. Arrangements must be made to provide adequate and suitable activities for service users. The registered person must ensure that all areas of the home and kept in a good state of repair, and kept clean and reasonably decorated. The registered person must ensure that external grounds which are suitable for, and safe for use by, service users are appropriately maintained. All parts of the care home must be kept free from offensive odours. The registered person must ensure that at all times adequate numbers of staff to meet the needs of the service users are working at the care home. The registered person must ensure that staff receive training appropriate to the work they perform. A training plan must be produced to demonstrate the way this requirement will be met, and sent to the CSCI within the timescale. DS0000015108.V293499.R01.S.doc 31/01/07 21/09/06 31/12/06 21/09/06 31/01/07 31/12/06 31/12/06 31/12/06 31/12/06 31/01/07 Rheola Version 5.1 Page 25 16 OP38 13(3), (4) & (5) 17 OP38 13(4)(a) All staff must receive training in 31/01/07 all topics related to health and safety, such as infection control, first aid, fire safety, food hygiene and manual handling. A training plan must be produced to demonstrate the way this requirement will be met, and sent to the CSCI within the timescale. The registered person must 31/12/06 ensure that all parts of the home to which service users have access are as far as reasonably practicable free from hazards to their safety. 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 OP9 Good Practice Recommendations The manager should consider updating the list of staff signatures at the front of the MAR charts folder so that staff’s initials on the charts can be identified. Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Rheola DS0000015108.V293499.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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