CARE HOMES FOR OLDER PEOPLE
Riverslie 79 Crosby Road South Waterloo Liverpool Merseyside L21 1EW Lead Inspector
Miss Diane Sharrock Ms Pat Carragher Key Unannounced Inspection 09:45 28 and 30th August 2007
th 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 Riverslie DS0000059055.V341090.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. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Riverslie Address 79 Crosby Road South Waterloo Liverpool Merseyside L21 1EW 0151 928 3243 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) Innocare Limited Michelle King Care Home 30 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (30) of places Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 30 OP and up to 1 LD. . Date of last inspection 15th March 2007 Brief Description of the Service: Riverslie is a Care Home with nursing and personal care only. In total the Home provides care for 30 service residents over retirement age. There are 22 single rooms and 4 double rooms, currently none with en-suite’s however there is a maintenance and refurbishment plan in place to provide a number of en-suites. Bedrooms are situated on all floors. There is a single lounge located on the ground floor and a dining area that has two separate sittings for lunch and dinner also located on the ground floor. Riverslie is a converted building on 3 storeys and provides a small passenger lift to all floors. There are gardens to the rear of the Home that are accessible from the ground floor. All areas of the Home are accessible to the residents and there are handrails and ramps provided throughout Riverslie for this purpose. Riverslie is situated in the Bootle area near to the local parks and the docks. The surrounding area is mainly residential. The Home is set back from a dual carriageway. Parking is available to the front of the building and there are main travel routes that provide easy access to the Home. Mr Salugetti is the Responsible Person and the registered manager is Mrs Michelle King. The manager has provided details for fees for the home which are from, £360 to £466.4 per week.
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 5 Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of two days and two inspectors were in attendance. During the inspection discussions took place with staff and residents. A total of 2 resident comments cards were forwarded to the commission (CSCI) with regard to the home and 1 staff comment card has since been submitted. A selection of comment cards had been sent before the inspection and some were left during the inspection for anybody to use and send back to the commission. The Inspectors completed this visit by looking at the homes records and undertaking a tour of the building. Inspections involve measuring a number of standards considered as important by the Commission. Feedback was given to the manager at the end of the inspection. A representative of the Primary Care Trust (pct) was present during this visit to observe the process of Inspection. What the service does well: What has improved since the last inspection?
Some improvements have been made following the previous inspection especially in training and development of Staff and in the management of policies and procedures in the home. The training matrix was detailed and showed a varied amount of training that had taken place.
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 7 Staff and resident and relative quality assurance questionnaires carried out in 2007 looked very positive in their comments about the home. The manager had developed an action plan following one survey on resident’s thoughts on nutrition and dining at the home to help improve this area and carry out the resident’s wishes. Quality assurance audits are carried out on a regular basis. These company audits help to show how the home is being managed to make sure the residents and staff opinions are taken into account and included in the development of the home. The manager has subscribed to the UKQCS Care Quality Management System, which is based on equality and diversity principles and is developed to maintain compliance with those same principles. The manager explains that she will continue to coach staff, supervise them in line with acceptable standards of performance; inform residents and staff of the level of behaviour in this respect that they should expect from others There has been some maintenance and decoration to some areas of the home and builders were seen in the process of developing ensuites to some of the current bedrooms. Finance records were much more organised and improved with clear records and receipts kept, so that auditing accounts was much more accurate. What they could do better:
This inspection was able to evidence improvements in some areas especially with the development of the residents care plans. However some issues needed to be developed further to meet the standards and show consistent improvements to the home. All concerns noted were discussed with the manager. Two immediate requirements were left regarding poor hygiene standards in the kitchen and the open gate outside the office window. An improvement plan has been requested from the company regarding what actions they will take to show how they will meet the regulations. Further work, development and management must take place to ensure all Residents needs are taken into account. Appropriate applications for variations must be submitted to CSCI as a matter of priority for any residents out of category. (This was repeated and noted at previous inspections.) Care plans did not always currently reflect all of the Residents needs. Care plans should continue to be developed to show evidence that they can meet all parts of the residents nursing, personal, social care and support needs.
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 8 Activities should continue to be reviewed so that resident’s opinions and needs are taken into account. Further work should be undertaken to ensure residents social and diverse needs are met. An organised programme of events should be easily accessible to all residents informing them of what events are planned for in their home including trips out. The development of suitable dining facilities for all the Residents must be provided and discussed with the Residents so their views can be taken in to account when developing this facility. A Staffing policy must be updated giving Staff clear instructions on the procedures for replacing Staff to ensure safe numbers of Staff are in place each day to meet the needs of all Residents at the home. Further training and support for staff should be arranged so they are aware of the policy and procedure for abuse awareness and in how complaints and suggestions should be encouraged and support given to residents. Some outstanding maintenance issues were in need of attention e.g The overall management of the kitchen area needed complete review including an immediate clean of all of the kitchen facilities to prevent any potential problems with cross infection and poor hygiene standards. A review of staff training needs should take place so that residents with specific diets have the right type of foods and menus offered. The building work and debris stored in the car park needed to be removed to make sure the building always had safe access out of the main exit areas. The external gate leading to the basement needed a risk assessment to describe what actions would be taken to reduce any risks of residents potentially falling down the stairs. The above concerns around the management of the environment have been noted on previous inspections. Some areas have improved but the ongoing work is not consistent in offering a well managed home to live in. 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. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 9 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 Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 10 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): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed before moving to the home in order to ensure their needs can be met. EVIDENCE: A review of one resident records showed a detailed assessment carried out prior to their admission. This helped the home to assess that they could meet the person’s needs. There was enough detail for staff to support the resident with their needs. The documentation in place covered all diverse needs of potential residents to the home ensuring the persons individual’s needs and requests could be met prior to moving into the home and they also included local authority assessments. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 11 Following the previous inspections the Manager had then previously explained that she had assessed all of the Residents at the home and felt that every residents is within the homes registration category. However during case tracking of care plans and in meeting various people one residents care plan had not described the persons mental health needs and there was no evidence of a professional care review, despite the manager trying to repeatedly arrange this with social services. The commission has not received an application for any resident considered out of category. Two residents spoken with gave the impression they have support needs associated with mental health. The home does not have a category of mental health and therefore an assessment of these residents is vital to ensure they receive the support they require. The staff do not always follow guidelines in applying for a variation with the Commission and they do not always have evidence in place with e.g. appropriate assessments to show how they could safely and adequately meet a persons needs. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The home did show they were adequately managing residents health and personal care needs. EVIDENCE: Four care plans were reviewed for case tracking. Most of the care plans gave details of the resident’s needs and the care and support required. The manager had invested in developing a new format for care plan records which included all necessary information including risk assessments, mental health assessments, a mental capacity assessment and individual likes and dislikes and social care plans and pen pictures. One care plan covered a residents needs such as, mobility, day care and support and social support. It also had recorded monthly reviews to check the care plan was appropriate and updated to meet the resident’s needs. One care plan for a resident recently admitted had various risk assessments and summaries of their needs but no care plan in place to show how their needs would be met and supported. One resident acknowledged they would
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 13 like support in contacting their family, however this was not described in their care records. This was discussed with the manager so that the resident could be supported in developing their own choices and be supported in their requests in maintaining relationships with their family. Discussions with residents revealed that they had faith in the staff and felt they were well cared for and staff were very helpful. The management of medications was mostly well managed. A sample of medication records and storage of medicines was seen during this visit. The medications and administrations were mostly found to be in good order. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate support to residents to meet their social needs but further work is needed to develop these needs further EVIDENCE: The home does not have an activities organiser and Staff are expected to manage and organise activities. Care Staff tried their best to implement some form of activities when they could. There had been no recent residents meetings and no evidence to show how they are involved in organising activities or making requests. The last recorded resident and relative meeting was dated march 07 and was shown to have a good turn out of people attending it. Four residents made comments regarding activities, ie “not much to do now the lady who did activities has left”. ” No suitable activities for me, and carers very busy” “staff don’t have time to do anything other than put on music or the tv” “ no one asks me what I would like to do” “Since being here I have not been out”
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 15 There was a programme of activities displayed but this was in the reception area and not easily accessible to some residents. Care plans have been developed to include sections regarding the support residents would need for activities including pen pictures. Not all of these care records are completed but the manager plans to have all of these records eventually completed for all of the residents at the home. Staff explained that Residents have bingo, quizzes and occasionally an entertainer and have a movie occasionally. Staff confirmed that residents do not really have outings. One resident stated, ” I would like to play bridge but there is no one here that is interested in that”. “I think visitors are welcome, but it is so embarrassing they do not get offered any tea, if you came to my house I would offer tea. The cups, plates ect are disgraceful and sometimes not clean, nothing nice about them.” It was acknowledged at the previous inspection that just 16 Residents were accommodated in the dining room and that the current dining area could not easily provide space for all Residents at the home. The manager has confirmed that initial plans to develop another room to provide further dining facilities will not be going ahead. It was noted that most areas in the kitchen were in need of deep cleaning and were in a poor state of cleanliness. As observed at the previous inspection in March 07, it was noted that the kitchen had a reduction to staffing levels and continues to operate without a kitchen assistant and the cook continues to manage the kitchen on her own. The cleanliness of the kitchen area continues to be an outstanding issue and an immediate requirement was served to make sure this area was clean and able to offer a safe and much improved area. The food management records observed were not up to date. Two residents were noted to be on specific diets however, there were no records kept of these diets which could impact upon the health and welfare of these residents. Two resident comment cards have been received to date. One states they always like the food, 1 states they usually like the food and suggests, “ Would like to see more fresh fruit made available.” Comments regarding the food from residents during this visit included, “”some food is ok, some is not”. “ Food is alright, plenty of it”. “Sometimes its ok, the cook is on a tight budget and sometimes the food is not up to much”.” “ I can have a choice of food, but sometimes its not good” Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 16 The manager had recently carried out a satisfaction survey with residents regarding the menus and dining at the home. From this the manager had taken into account the residents responses and produced an action plan so that further improvements and changes could be made to meet the resident’s comments and suggestions. The manager also had a draft table menu, which she is planning to offer so residents easily have access to the choice of meals throughout the day including breakfasts. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence including a visit to this service. Policies and procedures provide adequate support to protect and support residents, however not all staff understand them or carry them out and therefore residents may not be fully protected. EVIDENCE: Residents are protected by the homes policies regarding abuse and complaints procedures. The homes complaints record book was seen during this inspection; and the manager has also supplied a comment book for anyone to use and it is openly displayed by the entrance door but this is not always accessible to some residents living in the home. 2 resident comment cards state they always know who to complain to and are aware of the policy and who to speak to. Most residents said they knew how to make a complaint. Three residents were not confident to raise complaints because they felt they would be told off. One resident said , “I keep my mouth shut now” Residents felt staff were “Kind,” “caring” and they felt well cared for. One person stated, “I don’t make a point of making my concerns known now that I have been told off, I am never asked my opinion” The manager had carried out a staff survey this year, which had a good response, and the majority of comments were very good about the management of the home and positive about the changes in the home.
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 18 Staff discussions revealed that not all staff are aware of their responsibilities under the abuse awareness, (POVA) procedures. Most said they would report concerns from residents to the manager, however, staff are not always aware of their responsibilities should the manager not be available. A sample 3 Staff personnel files showed good recruitment checks are in place including the support and supervision of Staff with regularly training for staff in abuse awareness, recently carried out in 2007. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. The home mainly provides an adequate environment for residents to live in. EVIDENCE: There was one domestic Staff member on duty and as observed at the last inspection it was found that domestic hours had continued to provide just one person daily for domestic work. There has been some redecoration following the previous inspections and a selection of bedrooms had been updated and redecorated. The manager had developed a maintenance and development plan that had been shared with Residents and Staff to keep them informed about refurbishment of the home. Whilst it is acknowledged that there has been improvement within the environment, a tour of the building revealed the following areas of concern. Room 19 was malodorous, with the curtains dropped from the window.
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 20 Room 8, the frame of the bed was observed to be dusty and needed cleaning. The cup given to a resident at coffee break was observed to be dirty and not washed properly. Room 7 the ceiling was observed to have a damp patch above the window and paint was flaking from the ceiling. Toilets and bathrooms throughout the home need upgrading. The manager has developed and updated environmental risk assessments, which help to reduce or eliminate risks within the home. The maintenance person carries out weekly detailed fire safety checks which helps show how the home is being managed to ensure the safety of residents at the home. Some areas of risks were identified with the builders being present in the home; some amount of debris was stored outside in the car park by a main exit, an outside gate was noted to be open and led to steps in the basement area, the kitchen area was poorly managed and unclean offering unsafe standards of hygiene. These concerns were discussed with the manager who immediately carried out necessary work to reduce any highlighted risks. The manager organised a skip for the builders on site so that a main exit would not continue to be blocked. The manager has informed the commission following this visit that a risk assessment has been implemented for the gate and a contract cleaner had been in to the home to deep clean all areas of the kitchen. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Appropriately qualified staff support residents needs. EVIDENCE: Staffing rota’s indicated that staffing levels had been recently increased from 2 care staff to 3 care staff in the morning and afternoon. The manager did provide a file with evidence of weekly calculations to show how she assessed the staffing levels and how she linked them to the ongoing dependency levels of the residents. A recent staff meeting showed that staffing levels had been discussed with staff and a recent staff survey showed positive comments about how they feel about working at the home. The Manager organises a training matrix and showed recent training events attended by staff in 2007 covering a wide range of topics including moving and handling, food hygiene, abuse awareness, dementia etc. The homes pre inspection questionnaire gave details stating, 13 staff have NVQ qualification 2 and 12 staff working are already working towards it, which was evidence of a high number of staff with a training qualification in care. A sample of 3 Personnel files were looked at and were noted to be very organised and detailed with all necessary records and checks including police (CRB) and Protection of Vulnerable Adults (POVA) checks. This showed a good
Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 22 recruitment and selection policy, which helps to safe guard residents in the home. The personnel files showed that the support and supervision of staff had been developed and carried out. The manager had already made plans to develop supervision so that all staff are offered regular support throughout the year. This will help support staff in their training needs and help them develop while working at the home. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 23 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): 31/33/35/38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, welfare of residents and staff is adequately promoted. EVIDENCE: The manager is now registered with the commission following the previous inspection. Recent monthly reports (regulation 26 reports) were seen which showed that the provider is reviewing the care, the safety and management of the home. The manager has recently implemented updated policies and procedures, which have helped to evidence how the provider and manager now manage the home in the best interests of the residents. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 24 Samples of finances managed by the manager and the homes administer were reviewed during this inspection. Finance records were much more organised and improved with clear records and receipts kept, so that auditing accounts was much more accurate. Finances were only accessible by the manager who explained that they are now only acting as appointee for just one resident. Discussion with residents revealed that no secure, lockable facility is available to them to store small personal items such as money. One resident said, “ I can’t lock my money up and would like to have a drawer that could lock” “ I cannot lock up my money so have to leave it unsecured.” The company have various procedures in place to show how the home is being managed e.g. the inspector looked at a sample of maintenance certificates, fire safety checks and risk assessments which showed what actions were taken to ensure the safety of everyone at the home Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 25 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 26 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 OP13 Regulation 14 1(a)2(a)( b) Requirement All residents in the home must be within the category for which the home is registered, to ensure that the care home can meet the residents needs (repeated from previous inspections) Timescale for action 01/10/07 2. OP19 16 2 g)j) 3. OP19 13 4 a) 4. OP27 18 1 a) The kitchen must be cleaned 30/08/07 including the storerooms and kitchen equipment so that the kitchen area can be safely managed to prevent any potential risks of cross infections. The external open gate must be 30/08/07 closed and made safe so that residents are not at risk of falling down the steps. An appropriate risk assessment must be in place to reduce any identified risks. Staff must have suitable training 01/10/07 to provide appropriate diets for those residents needing specific meals and menus to enhance their health. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 27 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 OP12 Good Practice Recommendations Activities and care plans should be further planned and developed to meet resident’s needs including support with control and choices and contact with family members. To continuing development of regular minuted residents/relative meetings. The use of space within the home should be reviewed to ensure that sufficient room is available to residents including dining facilities. To update staff in the policies and procedures for abuse awareness and complaints and ensure all staff are aware of hoe to appropriate support residents especially in making a complaint or concern. The staffing levels should be kept under review in order to make sure that staffing levels are appropriate to the needs of the residents. Staff, residents and relatives comments and should continue to be taken into account when setting staffing levels. The homes staffing policy should be updated so staff are clear in what actions to take to replace any staff absences. 2. OP18 3. OP27 4. 5. OP32 OP26 To continue with ongoing and regular staff meetings and develop the implementation of appraisals. To review all areas of cleanliness in the home and take any actions necessary to provide an appropriate standard of cleanliness and refurbishment in the environment. To provide locked facilities in all residents’ bedrooms so they have their own area to provide suitable space for their private belongings. Riverslie DS0000059055.V341090.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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
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