Inspection on 29/08/07 for Risby Hall Nursing Home

This inspection was carried out on 29th August 2007.

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 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

Risby Hall Nursing Home 07/09/06

Risby Hall Nursing Home 03/10/05

Risby Hall Nursing Home 05/05/05

Risby Hall Nursing Home 01/02/05

Risby Hall Nursing Home 06/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Risby Hall Nursing Home Hall Lane Risby Bury St Edmunds Suffolk IP28 6RS Lead Inspector Jane Offord Key Unannounced Inspection 29th August 2007 09:30 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 DS0000024480.V349758.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. DS0000024480.V349758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Risby Hall Nursing Home Address Hall Lane Risby Bury St Edmunds Suffolk IP28 6RS 01284 810921 01284 811950 risbynursing home@btinternet.com 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) Risby Hall Nursing Home Limited Mrs Yvonne Ball Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34), of places Physical disability (4) DS0000024480.V349758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2006 Brief Description of the Service: Risby Hall is a care home for older people providing nursing care and has been established for many years under the proprietorship of Risby Hall Nursing Homes limited. The registered proprietors are actively involved in the management of the home. Risby Hall is situated on the edge of Risby village in West Suffolk and was converted from a farmhouse and outbuildings. The accommodation is all on the ground floor with level access throughout. The facilities are homely and comfortable and there are 20 single bedrooms and 7 shared rooms. The home registration was changed in 2006 to allow the home to accommodate service users with Dementia. The home can accommodate 34 service users. The fees for the home range between £370.00 and £620.00 weekly depending on the accommodation occupied and the level of support required. They do not cover hairdressing, newspapers, toiletries, clothing, chiropody or the cost of an escort for attending external appointments. DS0000024480.V349758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.30 and 16.30. The registered manager was on annual leave but the Quality Systems Manager was available most of the day and assisted with the inspection process by supplying files and information. This report has been compiled using information available prior to the visit and evidence found on the day. A tour of the building was undertaken with the Quality Systems Manager but all areas were revisited later in the day. The files and care plans of three new residents were seen, as were three new staff files. The policy folder, the complaints log, the duty rotas and a number of maintenance records were seen. Part of a medication administration round was followed and the medication administration records (MAR sheets) and the controlled drugs (CDs) register and stock were checked. The lunchtime meal was seen served and a number of residents and staff spoken with. The home was clean and tidy on the day although there was evidence of a shortage of storage space. No unpleasant odours were noted during the day. Residents looked relaxed and comfortable and enjoyed their lunch. Visitors came and went during the day and were made welcome by staff. Interactions between staff and residents were caring and appropriate. What the service does well: What has improved since the last inspection? The lounge carpet was renewed last year and some corridors have had matching carpet laid since then. A number of residents’ rooms have been redecorated and new lighting, soft furnishings and light furniture have been installed. DS0000024480.V349758.R01.S.doc Version 5.2 Page 6 The requirements made following the last key inspection in September 2006 were all actioned and the evidence seen during a random inspection that took place in February 2007. 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. The summary of this inspection report can be made available in other formats on request. DS0000024480.V349758.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 DS0000024480.V349758.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. Quality in this outcome area is good. People who use this service can expect to have sufficient information to make an informed choice about living in the home and have an assessment of need prior to entry. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Risby Hall has a comprehensive Statement of Purpose that is available to any prospective resident. It contains details of all aspects of life in the home. Risby Hall together with Risby Park, a sister home in the same grounds and owned by the same company, produce a joint Service Users’ Guide that was last updated in July 2007 and contains the terms and conditions of residence as well as other information about the services offered. This service does not offer intermediate care. DS0000024480.V349758.R01.S.doc Version 5.2 Page 9 The files of three newly admitted residents were seen and each contained a pre-admission assessment of need. The assessment covered the residents’ general condition, mobility, night needs, hearing and vision and the use of any aids or spectacles, oral care, dressing and undressing and personal hygiene. There was a record of the person’s preferred bathing method so one record noted, ‘XXXX does not like a bath’, while another noted, ‘YYYY would like a regular bath’. The assessment included the resident’s diet, continence, skin integrity, mental state and any known allergies. Details of leisure and social activities were recorded. Notes were made of the home situation and some life history work. DS0000024480.V349758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. People who use this service can expect to have a plan of care in place and be protected by medication practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is in the process of changing from written care plans to computer generated ones. When the system is fully operational each resident will have a complete file on the computer including an initial assessment on admission, a care plan developed from the assessment and risk assessments for any activity or need identified as a potential cause of harm to the resident. The care plan will be printed off and kept in the individual’s bedroom for easy reference for carers and to give residents ownership of the document. The staff have been given additional I.T. training to help them manage the new system. Staff spoken with said they were slowly getting used to it. DS0000024480.V349758.R01.S.doc Version 5.2 Page 11 Three new residents’ care plans were accessed on the computer and showed they were compiled from the initial assessment of need made after admission. The care plan for one resident, who had suffered a stroke and needed careful management during moving and handling processes, contained details of the hoist and sling to be used and that the person needed a profiling bed. Other care plans had detailed instructions for areas of care. One for night needs said, ‘XXXX likes the window closed and the door open’, another for personal hygiene encouraged independence, ‘YYYY can apply their own deodorant and powder’. One resident with an assessment saying they would like a regular bath had no entry on the daily records since admission to indicate that they had had a bath or been offered one and refused it. There were risk assessments for moving and handling and skin integrity with evidence that when the scores showed a resident was at risk action was taken to minimise it. So for a resident with a high Waterlow score for risk of skin damage an air mattress was in place and a propad cushion used in their armchair. A resident with weight loss and a low Body Mass Index (BMI) had been referred to a dietician. Part of the lunchtime medication administration round was followed and the MAR sheets inspected. The MAR sheet folder had a sheet of specimen signatures inside of the people qualified to give medication. The home uses a monitored dose system (MDS) so tablets are pre-packed in blister packs for individual residents by a pharmacist. No signature gaps in the boxes were noted but when a medicine was prescribed with a choice of dose i.e. one tablet or two, 5mls or 10mls, the amount given was not always recorded making an audit trail impossible. Some boxed medication was checked against the ‘carry forward’ figures and they tallied. One signature error on a MAR sheet had been scribbled through instead of barred with a single stroke. The medicine trolleys were kept securely in the nurses’ office and during the round it was noted that they were locked each time they were unattended. The controlled drugs (CDs) register and stocks were checked and the stock tallied with the records. The nurse doing the medication round said they had recently had updated medication training and this was confirmed in the training records seen. The medication policy was seen and gave comprehensive guidance on storage, administration and disposal of medicines. It also contained procedures for the management of homely remedies, covert administration of medicines, the refusal by a resident to take prescribed medicine and the assessment and practice for residents who wish to self-medicate. DS0000024480.V349758.R01.S.doc Version 5.2 Page 12 Details of health professionals involved with the residents were recorded such as chiropodist, optician and GP. Records of visits to or by the health professionals were recorded and any treatment prescribed or changed was noted. Care practice was observed during the day and staff spoke respectfully to residents and offered them choice about where they wished to be. People who needed help at lunchtime were assisted sensitively and not hurried. It was noted that shared rooms had screens for use to maintain privacy during personal care. Residents spoken with said they found staff friendly and polite. During the afternoon a resident got up from a chair in the main lounge and fell over. The nurses and carers reacted quickly finding a hoist to get the resident up but when the resident said they could not move their leg it was decided to call 999 and wait for the paramedics. As the incident happened in the main lounge there were a number of people around so staff found screens and a blanket and pillow to make the resident as comfortable as possible and preserve their privacy while waiting. DS0000024480.V349758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. People who use this service can expect to be offered a well-balanced diet and meaningful pastimes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a team of activities co-ordinators who work between Risby Hall and the sister home Risby Park. Activities organised in either home are open to all residents of the complex. Pastimes organised include flower arranging, bingo, board games and jigsaws, craftwork and music. On the day of inspection there was a sing along to old favourites taking place in the lounge. Special events are planned for Easter and Christmas as well as other significant dates in the year. Residents’ birthdays are celebrated with a special tea and cake. Weekly activities are announced on the notice boards around the home and included many opportunities for residents to have one-to-one with the activities staff who are also responsible for ascertaining the residents’ choice of meals for the week. DS0000024480.V349758.R01.S.doc Version 5.2 Page 14 Residents’ files and care plans included their special interests and their social and leisure needs. Their preference of daily newspaper was noted if they wished for one. The home has visits from a mobile library for resident who enjoy reading. Representatives of various religious denominations visit the home regularly and hold general or private prayers. The home has the use of a minibus with wheelchair access to use for outings to places of interest and shopping trips. Photographs taken of some events were on display. However some staff and residents said that there were still long periods when no activities took place or were limited to a few residents. As Risby Hall is now a secured home residents are reliant on staff to help them access any activities in Risby Park. The home has a policy of welcoming visitors at any reasonable time and a number were seen to come and go during the day. The home is in the process of altering one of the bedrooms into a small family room so residents can meet friends and family in private but not use their bedroom. Unfortunately there has been a setback to the alterations as one of the walls has shown signs of damp and has needed to be completely stripped back and treated. It will be a useful and attractive facility when completed. The lunchtime meal was seen served in the main dining area in the lounge. Some residents chose to have their meal in their rooms and these were taken to them on trays using plate covers to keep the food hot. The main choice of meal was beef and Yorkshire pudding with vegetables and gravy but a number of options were in evidence including soup and salad. For dessert there was a choice between chocolate or raspberry mousse, yoghurts and fresh fruit. Residents spoken with said they had enjoyed their lunch. Some residents needed a soft diet and these were served with items pureed but separate on the plate. In discussion with the cook later it was clear that they were aware of residents with a poor appetite and included additional calories in some meals by adding cream or butter to things like mashed potato. After lunch residents are given the choice of what they wish to do and some chose to return to their room and have a rest on their bed. Visiting some of these rooms later in the afternoon one resident asked where their call bell was, as they could not find it. It was discovered on the floor under the bed and placed on the bed so the resident could use it if required. It was noted that at least one other resident did not have their call bell within reach while on their bed. DS0000024480.V349758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. People who use this service can expect to have concerns taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Risby Hall has a robust complaints policy that is available in the service users’ guide and the welcome pack left in each resident’s room. The policy is also displayed on the notice board at the entrance of the home. In a recent residents’ survey conducted by the home twelve residents responded and all twelve said they knew how to make a complaint if they needed to. The complaints log was seen and contained six entries for this year. They ranged from missing clothing to a complaint from a speech and language therapist that instructions they had left for a particular resident were not being observed. Each complaint was investigated and responded to in writing. Copies of the paperwork were in the file. In most cases it was recorded that the complainant replied that they were satisfied with the response. In one case action was taken to retrain a member of staff in certain care practices. Records showed that care and ancillary staff had received protection of vulnerable adults (POVA) training this year and it was confirmed in discussion with staff who were clear about their duty of care. DS0000024480.V349758.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. People who use this service can expect to live in a well-maintained environment but cannot be assured that all aspects of infection control will be enforced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Risby Hall is a converted farm and outbuildings with all the accommodation on the ground floor level. It is a rambling building with a large central lounge that has a dining area to one side. The dining space is not large enough to seat all the residents at once and many had their lunch in their armchairs on the day of inspection. The lounge and some corridors have recently had new carpet fitted and some residents’ rooms have been redecorated and had new lighting, soft furnishings and new light wood furniture supplied. DS0000024480.V349758.R01.S.doc Version 5.2 Page 17 The conversion of one room to a small ‘family’ room, so residents can meet visitors in private but not in their bedroom, has been held up with the discovery that one wall needs damp proof treatment. The room is being used for storage until the work is completed. There was evidence throughout the home of a lack of storage space with continence pads stored in the hairdresser’s room, commodes in one of the bathrooms and a collection of items on free standing shelving at the end of one corridor. Residents’ rooms that were seen were small but light with big windows generally overlooking the gardens. All the rooms were personalised with photographs, ornaments and sometimes small items of furniture. Some rooms were identified with large pictures on the outside of the door so a resident with dementia could find their own room easily. There were no unpleasant odours noted during the day. The laundry was visited during the day and contained washing machines with a sluice programme for the management of soiled linen. The infection control policy was seen and covered the management of soiled linen using alginate bags for transporting and washing it without staff having to handle it unnecessarily. Protective clothing was available for staff use. During the lunchtime a member of staff was seen transporting dirty laundry through the dining room. The Quality Systems Manager said they would speak to the member of staff and the nurses about the practice. A door in the laundry has been opened to access the garden and some days clothing is dried outside on a line rather than using the tumble dryer. However to achieve access the hand washing basin has been removed from the laundry leaving nothing for staff to wash their hands at before leaving the room. DS0000024480.V349758.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. People who use this service can expect to be supported by adequate numbers of correctly recruited staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed the care team had four registered nurses and four care staff on duty during the morning with one registered nurse and four care staff covering a late shift. One registered nurse and two care staff managed night duty. The manager was supernumerary and an ancillary team of domestics, kitchen staff, an administrator and maintenance staff, supported the care team. The management team of Risby Homes Ltd. is based on the site and accessible if required. The files of three new members of staff were seen and all contained evidence of identification checks being made using birth certificates and passports as proof. Each one had a POVA 1st check undertaken prior to commencing work and two contained evidence of a criminal records bureau (CRB) check. The third showed that a CRB had been requested but had not yet arrived although the administrator had followed up the cause for the delay. All the files had a copy of the contract detailing the terms and conditions of employment. DS0000024480.V349758.R01.S.doc Version 5.2 Page 19 The files all contained evidence of an induction programme carried out over the first few weeks of employment. The induction covered fire, health and safety, infection control, communication, moving and handling, confidentiality and control of substances hazardous to health (COSHH) regulations. In addition care staff had instruction on care planning and received a booklet entitled Code of Practice for social care workers. Training records were seen and showed that all staff both care and ancillary have been to training sessions covering fire awareness, recognition of abuse, moving and handling, infection control and nutrition. Care staff have had instruction in the principles of care, falls prevention and dementia. Some nurses have had updated medication and wound care training and this was confirmed in discussion with the nurse who administered the lunchtime medication. There were certificates to show that the registered manager had also attended a number of the training sessions. DS0000024480.V349758.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. People who use this service can expect to be consulted about the home and be protected by management practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has several years experience in management in nursing homes and is a registered nurse. She is also a registered midwife and a distance learning tutor. She is usually available in the home on weekdays and staff spoken with said she was approachable and supportive. DS0000024480.V349758.R01.S.doc Version 5.2 Page 21 Risby Hall have undertaken a residents’ survey this year and the responses have been collated and results are available. Twelve residents responded to questions about their care, their privacy, staff attitudes, housekeeping and meals. Most responses indicated a high level of satisfaction with the service offered; only two said the meals could be improved. Minutes of a residents’ meeting held in May 2007 were seen. A variety of subjects were discussed including catering, new notice boards and the availability of the minibus for planning outings. In discussion with the home’s administrator it was clear that the home does not hold any personal money for residents. Any additional items to the fees are invoiced to the resident or the representative responsible for their finances. A lockable drawer is provided to any resident who wishes to have that security in their room. In the staff files seen there was evidence of regular supervision and a supervision contract. Staff spoken with said they had supervision every six to eight weeks and could discuss any issues with their supervisor. Training needs were identified during the sessions and any areas of practice that could be developed by the individual. A number of maintenance records were inspected and showed that fire fighting equipment and emergency lighting is checked weekly and hoists, fire alarms and filters on washing machines are checked monthly. Six monthly checks are done on extractor fans and the temperatures of bath water. The fire log showed that there were regular fire drills for staff. Recorded temperatures of refrigerators and freezers in the kitchen showed they were functioning within safe limits for food storage. DS0000024480.V349758.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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 DS0000024480.V349758.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 OP9 Regulation 13 (2) Requirement When a prescription gives a choice of dose for a medication such as 1 tablet or 2 the amount administered must be recorded to ensure the safety of the resident and allow an audit trail. During mealtimes bags of soiled laundry must not be carried through the dining area to protect residents from cross infection and make mealtimes a pleasurable experience. Hand washing facilities must be installed in the laundry at the earliest opportunity to ensure staff and residents are protected from cross infection. Residents’ choice of activity should not mean that they cannot contact staff at any time so staff must make sure residents always have access to a call bell for their security. Timescale for action 29/08/07 2. OP26 13 (3) 29/08/07 3. OP26 13 (3) 30/09/07 4. OP12 13 (4) (c) 29/08/07 DS0000024480.V349758.R01.S.doc Version 5.2 Page 24 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 OP19 Good Practice Recommendations Consideration should be urgently given to the provision of more storage space for equipment and continence pads to make the environment as attractive as possible for residents. DS0000024480.V349758.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000024480.V349758.R01.S.doc Version 5.2 Page 26 - 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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