Inspection on 07/06/06 for Rock House

This inspection was carried out on 7th June 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

Rock House 27/07/07

Rock House 21/10/05

Rock House 23/05/05

Rock House 11/10/04

Rock House 04/05/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Rock House Austenwood Lane Chalfont St Peter Bucks SL9 9DF Lead Inspector Christine Sidwell Unannounced Inspection 09:30 7 and 9th June 2006 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 DS0000023015.V290782.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. DS0000023015.V290782.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rock House Address Austenwood Lane Chalfont St Peter Bucks SL9 9DF 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) 01753 882194 office.rockhouse@btinternet.com Gold Hill Housing Association Limited Susan Shadloo Care Home 38 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (38) of places DS0000023015.V290782.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That as of the 5th September 2005, the home is registered to provide care for up to 10 (ten) Service Users with a Dementia-type Illness. 21st October 2005 Date of last inspection Brief Description of the Service: Rock House is a care home for older people, offering personal care and accommodation for thirty-eight service users who are elderly and physically or mentally frail. The home is owned by Gold Hill Housing Association, a Friendly Society. It is located in Chalfont St Peter, at the top of Gold Hill Common. It is close to shops, public houses, the post office and other amenities. Rock House was developed from two large semi-detached houses and has three floors. Access to floors is via a passenger lift. All the homes bedrooms are single and twelve of the bedrooms have en suite facilities. The home has its own landscaped garden. The home has a strong Christian ethic. Fees, as of June 2006, range from £360 -£530 per week. Additional charges are made for manicures, hairdressing, chiropody, newspapers, dry cleaning, additional care provided through a buddy system and transport to external events. Information about the home can be obtained by telephoning the home, visiting their website www.rockhouse.org.uk or by visiting the home. DS0000023015.V290782.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of six days. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of previous inspections noted. Ten questionnaires were sent to service users and their families and four were returned. Residents and those family members who were visiting on the days of the fieldwork were interviewed. A tour of the premises was undertaken and records held in the home were scrutinised. The care of a number of residents was ‘case tracked’ from their original contact with the home to the care that they are now receiving. Care practices and the home’s approach to quality and diversity issues were observed. What the service does well: What has improved since the last inspection? The home’s statement of purpose and service user’s guide has been improved and now contains more information for potential residents to assess whether the home can meet their needs and is more explicit about the financial commitments that potential residents would be entering into. Fire safety and control of infection procedures have been improved to protect staff and residents. Recruitment procedures have improved and staff are now checked more thoroughly before being employed in the home. DS0000023015.V290782.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000023015.V290782.R01.S.doc Version 5.1 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 DS0000023015.V290782.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the home. The information that potential residents receive has been improved since the last inspection and now gives potential residents more information on which to decide whether the home can meet their needs. The pre- assessment procedures should be improved if the home is to be sure that it can meet resident’s needs and all residents should have a statement of terms and conditions or a contract in order that they are clear as their and the homes commitment. EVIDENCE: The home’s statement of purpose has been updated since the last inspection and now meets the criteria stipulated in the National Minimum Standards. Both the statement of purpose and the service user’s guide are now explicit about the level of fees charged and the additional fees that may be incurred by service users. There is a sample contract in the service user’s guide. The sample contract meets the requirements of the National Minimum Standards. The Chief Executive said that residents who were sponsored by social services would have a care service order and not a contract. The care records of the DS0000023015.V290782.R01.S.doc Version 5.1 Page 9 last person to move to the home were seen. The resident had been assessed in hospital although the assessment was incomplete. The manager stated that she was staying for three months on respite care and did not have a contract. The Chief Executive also said that fully funded private clients would be encouraged to have a contract. Three other resident’s files were seen. They had completed care service orders and two contained assessments undertaken by the home prior to admission. There is a need to ensure that all potential residents are assessed prior to their admission to the home and that all residents are provided with a statement of terms and conditions when they move to the home, irrespective of how long they expect to stay. Privately funded residents should have a full contract, which specifies not only the terms and conditions of their stay but the fees payable and any additional charges that may be incurred. The home does not offer intermediate care. DS0000023015.V290782.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the home. Although resident’s personal and healthcare needs are generally met there remain important areas of care for which improvements are necessary if resident’s personal and healthcare needs are to be met fully. EVIDENCE: Four resident’s care plans were looked at in detail. The initial admission sheets had been completed and all had risk assessments although identified risk was not always followed up with a care plan. There is a separate review sheet, which shows that plans are updated on a monthly basis. One resident only had admission details and did not have a care plan. The daily entries for this resident identified a number of care needs for which a plan was required. The care plans also identified a number of care needs for which specialist advice would have been helpful and had not been sought. Most residents are registered with the same local General Practitioner although some had elected to stay with their own General Practitioner. There was evidence in the files that the district nurse visits the home. The manager said DS0000023015.V290782.R01.S.doc Version 5.1 Page 11 that she had asked for advice from the local Primary Care Trust’ Care Homes team about promoting continence and preventing falls. Oral hygiene needs are included in the care plan on a needs only basis. Not all of those residents who had teeth had had an annual check up with the dentist. One resident has pressure damage although her care plan did not reflect her changing needs. She had also lost considerable amounts of weight and did not have a nutritional assessment and had not been seen by a dietician. The home does not possess weigh scales, which a resident can sit on to be weighed and therefore those residents who cannot stand are not weighed regularly. There is a mobility assessment although not all residents have had a falls assessment. The manager said that resident’s physiotherapy assessment, hearing tests and advice from the community psychiatric nurse could be obtained on referral by the general practitioner. Medication policies and procedures are in place. No residents manage their own medication at present. It is recommended that a self-administration of medication policy be implemented and that those residents who wish to do so be encouraged. Secure storage should be provided in their rooms. A dosette system supplied by the local pharmacist is used. Records of medication received by the home and returned are kept. There is a locked medication trolley. Additional kitchen cupboards in the large room adjacent to the kitchen are used to store additional medication. These are not locked. One cupboard contained a locked tin containing the controlled drugs. This was not secured. Three residents were taking controlled drugs and the controlled drugs register was completed correctly. The medication administration records were examined and two omissions without explanation were noted. A second cupboard contained drink supplements, cough medicines, lactulose and cranberry tablets. There did not appear to be homely remedies policies in place. Only one bottle of lactulose is kept in the medicine trolley and it appears that this bottle is shared. There were also senokot tablets in the trolley, without a pharmacist’s label, for a resident whom is prescribed lactulose. Senokot was not prescribed on the treatment sheet. There were two dosette boxes without names on. The management of medication should be improved in line with guidance issued by the Royal Society of Pharmacists. Personal care is delivered in resident’s rooms. Residents wear their own clothes and there are no shared rooms at present. Four residents were interviewed and all said that they had seen the general practitioner recently. DS0000023015.V290782.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to the home. The activities offered in the home are excellent and were clearly enjoyed by residents and appreciated by families. Resident’s privacy and dignity is maintained. The residents said that they enjoyed their food although there are improvements that should be made to the presentation of meals and to the dining environment. EVIDENCE: There is a positive approach to activities in the home. The activities coordinator was interviewed. There are approximately forty to fifty staff hours per week devoted to leading activities. On the day of the unannounced inspection, different activities were taking place in each of the lounges. A cross word group was doing the daily cross word in one lounge, a ‘football special’ display was being arranged to remind residents that the world cup was being held and one lady was playing the piano with a carer. One gentleman had planted some tubs for the front door. One resident spoken to said that he enjoyed a walk on the common and that a staff member would always take him if he wished. This is a Christian home and a ‘thought for the day’ is discussed in the mornings and a there is a short period of praise after lunch. Bible studies are a regular feature of the day. The activities coordinator said that the home has an ecumenical approach. One family member wrote, in DS0000023015.V290782.R01.S.doc Version 5.1 Page 13 response to the inspection, to say that her mother had settled in well at the home. She said that ‘ this is due to the care of the staff and the wonderful mind games that are held on a daily basis –crosswords, scrabble, word games, bingo and quizzes’. She also commented that her mother enjoyed the music and movement and has gone on outings during the year. Information about the activities is posted throughout the home. One resident said that he was aware of the activities but that his wish not to participate in everything was respected. Residents could receive visitors in private in their rooms although the lounges are rather crowded. The staff said that visitors are welcome at the home at any time. The Christian nature of the home and its involvement with the local church is clear in the statement of purpose and the residents spoken said that they were happy with this. Resident’s choices as to how they spend their day are limited to a certain extent by the routines of the home and the staffing levels although the residents spoken to understood the need for this. There was information about local advocacy services in the home. The menus are varied although residents do not receive a choice of hot main meal. The inspector was told that if the resident did not like the main meal a salad could be offered. There are two dining rooms. One was very crowded and staff were observed to be talking amongst themselves and not to the residents. One resident needed help with her meal. This had been pureed. Each food item had been pureed separately although the meal was then served in a bowl and the items stirred up. The portions were small. One table had four gentlemen sitting on it and the inspector felt that the size of the shepherd pie served was only sufficient for two. Second helpings were not possible as there was none left. One carer said that she felt residents should have a choice of main meal. The residents spoken to however said that they enjoyed the food. The chef also provides meals for staff, those living in the sheltered housing complex on the site and for others living in the community. The chef said that she might have to prepare up to 150 meals a day. Twelve residents were given their medication during the mealtime. It is recommended that the menus be reviewed to offer a choice of main meal, that pureed foods are presented more attractively and that consideration is given to ways in which the crowded feel in the dining room is reduced. Portion sizes should be monitored. Medication should not be administered at mealtimes unless it is necessary for a particular medication to be given with food. DS0000023015.V290782.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the home. The philosophy of care at Rock House is to respect resident’s individuality and to enable them to air their views. This philosophy is not always put into practice and all complaints must be acknowledged and responded to. All staff including the management team should have training in current safeguarding procedures if residents are to be fully protected from physical, emotional or financial abuse. EVIDENCE: There are complaints and protection of vulnerable adult policies and procedures in place. There is a complaints log although this was not found to be up to date and not all complaints had received a written response. The home’s complaints policy is clearly described in the resident’s guide. The resident’s guide states that details of complaints will be available to the management committee and to The Commission for Social Care Inspection. The statement of purpose and residents guide describes the philosophy of care, which is clear about the need to respect individuals right to respect and to make their own choices. The home has a copy of the Buckinghamshire County Council Multi-agency Protection of Vulnerable Adults policies and procedures and the manager was able to describe the application of this procedure. Not all staff had had training in safeguarding issues although some had. All staff interviewed said that they would report issues of concern to the manager. It is recommended that all staff including the new management team should have Protection of Vulnerable Adult training. DS0000023015.V290782.R01.S.doc Version 5.1 Page 15 DS0000023015.V290782.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, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the home. Although homely for residents, the home is in need of refurbishment and the lounge furniture, particularly some of the armchairs, is in need of replacement. EVIDENCE: There is a programme of maintenance although in general the home is in need of refurbishment. There is an annual repairs budget. The pre-inspection questionnaire did not identify any major repairs during the last year but referred to ‘various areas redecorated’. The Chief Executive said that the next major items to be addressed were the hot water systems and the fire alarms. Many residents had personalised their rooms with their own furniture and belongings. Some rooms have ensuite areas, which are screened by curtains to make use of all available space. Some of the furniture in the lounges is of poor quality and armchairs need replacing. All rooms are carpeted. There was DS0000023015.V290782.R01.S.doc Version 5.1 Page 17 a lingering odour of urine in one bedroom. Not all residents have lockable space in their rooms for medication or valuables. In general the home was clean and tidy on the day of the inspection. The laundry is situated away from the kitchen and was clean and tidy. The floor and walls and walls of the laundry are impermeable. There is a red bag system for separating soiled laundry. The bags are intended to be put into the washing machine to reduce the risk of cross infection although on the day of the inspection they were overfilled and the laundry assistant had to empty them in order to get them into the washing machines. This must be addressed and the carers should be asked not to overfill laundry bags. Some staff have had training in infection control. There are hand washing facilities. DS0000023015.V290782.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 and 30 Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the home. The home’s recruitment, induction and training programmes are improving and are giving staff greater knowledge and skills to care for residents. EVIDENCE: There is a staff records which shows the number of staff on duty. The staffing hours provided met the levels recommended by the department of health. Two residents said that staff were always available to help them and three of the members of staff spoken to felt that they had time to care for residents. There are a number of staff and volunteers who are under 18. The manager said that they did not offer personal care to residents. The home is an accredited national Vocational Qualification Centre and there are programmes in place to enable staff to gain this award Six members of staff hold the National Vocational Qualifications in Care at level 2 or above and a further five are undertaking the award. There are twenty eight care staff in all. The home does not meet the standard that 50 of all staff hold the National Vocational Qualifications in Care at level 2 or above but has the systems in place to work towards this. The recruitment records of five staff members were examined. All had completed an application form and had two references, one from the last employer. A POVA first check had been sought and the manager said that staff DS0000023015.V290782.R01.S.doc Version 5.1 Page 19 were supervised if they commenced work before the full Criminal Records Bureau disclosure had been received. There is a need to ensure that this is fully documented. The personnel assistant was in the process of ensuring that the residency status and work permit status was on file for appropriate staff New staff have commenced the in house induction programme and some are now undertaking a ‘Skills for Care accredited induction programme. The home has training programmes in place to cover specialist care needs of residents and the staff spoken to valued their training and said that it was in paid time. Staff are given literature relating to the care of people who have dementia when they join the home and some staff have had training in this topic. DS0000023015.V290782.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, 34, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the home. Overall the management of the home provides a stable environment for residents. The quality assurance programme should be further developed and an annual development plan should be agreed to ensure that the care that residents receive continues to improve. EVIDENCE: There is an experienced manager, who holds the National Vocational Qualifications in care and Management at level 4. She has had experience of managing a care home for older people. The staff said that the management atmosphere was open and that their views were listened to. There is a Board of Trustees and an executive management committee who manage the day-to-day running of the home. It was planned to improve the home by building an extension although that has had to be changed because of DS0000023015.V290782.R01.S.doc Version 5.1 Page 21 planning constraints. It is now necessary for the Trustees and the management committee to agree a development plan for the home, which addresses both the environment and the service model that they wish to offer for the future. An annual quality assurance survey is undertaken and is made available for this inspection and is published on the homes website. Although there are some outstanding issues regarding outstanding requirements from previous inspection reports most have been acted upon. A member of the trustees undertakes regular quality assurance visits to the home, although there is no specific format to guide them in completing this visit. The trustees do not receive a full copy of The Commission for Social Care Inspection reports and it is recommended that they do so. The home does not have a systematic quality assurance programme whereby all aspects of care and administration of the home are assessed on a regular basis. Audited financial accounts are prepared. The accounts cover the work of the Housing Association as a whole and include the accounts for the sheltered housing and domiciliary care service in the association. The accounts show that there is a deficit in home’s operating costs although the association as a whole has sufficient reserves to maintain financial viability. The budget statements for the first quarter of 2006 showed that operating costs were in balance. Insurance cover is in place. The statement of purpose refers to a charge regarding handling residents personal finances. The Chief Executive said that that referred to one resident only and that the home does not now deal with any resident’s finances. It is recommended that this be removed from the statement of purpose to avoid any confusion. The home does not hold personal allowance on behalf of residents and the Chief Executive said that any items that resident’s need would be purchased and the relative or appointed person invoiced. There is a health and safety policy. There are manual handling policies in place and staff said that they had had manual handling training. The training matrix however showed that not all staff had had manual handling training or annual updates. This must be addressed. The home is working with another home to share the cost of training and there are plans for infection control, first aid and health and safety training during the next four months. The preinspection questionnaire showed that regular maintenance of equipment is undertaken. The fire log was seen and evidence that fire checks have been undertaken. The staff spoken to could describe the fire evacuation policy. The chief executive said that the fire alarms were the next major refurbishment for the home. Hold open devices have been fitted with the agreement of the Fire service. Accidents are recorded. A serious incident has occurred recently which was reported appropriately. A follow up visit was undertaken by the Health and Safety Executive and an action plan to prevent further occurrences agreed. DS0000023015.V290782.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 3 1 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 X X 2 DS0000023015.V290782.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 OP2 Regulation 12 Requirement All residents should have a statement of terms and conditions and if privately funded a contract, specifying terms and conditions and fees payable. Potential residents should be fully assessed prior to their move to the home All residents must have a care plan, which reflects their current care needs and the plan to address these. Residents and their families must be involved in drawing up and reviewing their plan All residents must have a nutritional assessment and be weighed regularly. The advice of the dietician should be sought where there is a significant change in weight and where a resident has pressure damage. Sit on weigh scales should be purchased in order to weigh those who cannot stand. All residents with pressure damage should have a care plan and the rate of healing be monitored and recorded DS0000023015.V290782.R01.S.doc Timescale for action 30/09/06 2 3 OP3 OP7 14 15 30/09/06 30/09/06 4 5 OP7 OP8 15 13 30/09/06 30/09/06 6 OP8 13 30/09/06 Version 5.1 Page 24 7 8 OP8 OP8 13 13 9 OP8 13 10 OP9 13 11 OP9 13 12 OP9 13 13. OP9 13(2) 14 OP16 22 15 OP18 13 16 OP19 23 regularly. Those residents with teeth should have an annual dental check up. The falls policy should be revised and a clear policy regarding falls assessments be implemented. Specialist advice should be sought on this. All residents should have a continence assessment and a care plan to promote their continence. Medication administration records must be completed fully and reasons why a resident has not taken the medication recorded. The controlled drugs tin should be secured or preferably a purposely-designed controlled drugs cupboard be purchased. Homely remedies policies should be developed and agreed with the general practitioner for each resident. The registered manager must ensure that prescribed medications for residents are recorded on the medication administration record sheets. This is an unmet requirement of previous reports and a new timescale has been set. The complaints log should be fully maintained, each complaint responded to and an analysis of complaints made to identify themes as part of the quality assurance processes. Regular reports to the Trustees should be made. All staff including the management team should have Protection of Vulnerable Adults training. A development plan and refurbishment plan should be DS0000023015.V290782.R01.S.doc 31/12/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 31/12/06 31/12/06 Page 25 Version 5.1 17 18 19 OP26 OP30 OP33 13 13 24 20 OP38 13 agreed by the Trustees Soiled laundry bags should not be overfilled and dealt with appropriately in the laundry. All staff should have basic mandatory training with annual updates. The quality assurance programme should be developed to ensure that all aspects of the care and management of the home are audited on a regular basis. All staff should have manual handling training with annual updates. 30/09/06 31/12/06 31/12/06 30/09/06 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 2 Refer to Standard OP9 OP15 Good Practice Recommendations It is recommended that a policy regarding selfadministration of medication be implemented and secure storage provided for medication in resident’s rooms. It is recommended that a choice of meal be offered at the main course. And that pureed meals are presented more attractively. The overcrowding in the dining room should be reduced. DS0000023015.V290782.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000023015.V290782.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!