Inspection on 15/10/07 for Roman Court

This inspection was carried out on 15th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Roman Court 16/11/06

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

CARE HOMES FOR OLDER PEOPLE Roman Court Old Farm Court Mexborough S64 9ES Lead Inspector Ian Hall Key Unannounced Inspection 15th October 2007 09:00 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 DS0000067664.V350496.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. DS0000067664.V350496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roman Court Address Old Farm Court Mexborough S64 9ES 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) 01709 584986 F/P 01709 584986 gwen.bates@btconnect.com Home and Care Limited Post vacant Care Home 35 Category(ies) of Dementia - over 65 years of age (35) registration, with number of places DS0000067664.V350496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care need on admission to the home are within the following categories: Dementia - Code DE(E). The maximum number of service users who can be accommodated is: 35. To be able to admit residents of 60 years of age and above. To provide care for one named person aged 57 years. 2. 3. 4. Date of last inspection 16th November 2006 Brief Description of the Service: Roman Court is a purpose built home catering for a maximum of 35 older people with dementia. It is situated in a residential district of Mexborough and is well served with public transport. There is limited car parking space at the home, however on street parking is readily available. People’s accommodation is all in single bedrooms these are located on both ground and first floor levels. There is level access throughout the home with the first floor being accessed by means of a passenger lift or choice of 2 staircases. The communal areas comprise two main lounges with an adjacent dining room. Additional smaller seating areas and lounges are located and available on both floors of the home. A communal area is set aside for people to have a cigarette with staff supervision as appropriate. An internal sheltered and secure garden with seating is readily accessed from the lounge area. People are able to exercise and benefit from an aromatic garden with flowers and plants whilst easily observing staff and fellow people. The weekly fees are from £385.00 to £416.00 this information was provided on the 10th October 2007. The home charges extra for chiropody, toiletries, clothing, telephone calls, holidays and hairdressing. The last CSCI inspection report is available in the entrance to Roman Court. DS0000067664.V350496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over 8 hours. The inspector was joined by a Social Worker as part of an ongoing Adult Protection investigation. We had received information regarding the care standards and practises at the home in November 2006, June 2007 and September 2007. Some of this detail is now being processed via Adult Safeguarding procedures. As a result the home had random inspections on 21st June 2007, 21st September 2007 and a random inspection by the CSCI pharmacy inspector on 3rd October 2007. Summarised findings from these visits are within this report. During the inspection the inspector spoke to 5 people who live at the home, 2 relatives and 5 staff members. People spoken with were happy to provide comment to assist with the inspection. The home’s acting manager and the professional advisor was present for part of the inspection. We were unable to use the home’s self-assessment, the Annual Quality Assurance Assessment (AQUA) as part of the inspection. This had not been returned as required prior to the visit. At the end of the inspection verbal feedback was given to the homes acting manager and professional advisor. A telephone conversation was made to Mr Johal son of Mr Johal a director of the company which owns the home to discuss ongoing requirements and fresh concerns that were raised by the inspection. What the service does well: What has improved since the last inspection? Further training has been provided for staff. DS0000067664.V350496.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000067664.V350496.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 DS0000067664.V350496.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 and 6. People who use the service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The information provided was incomplete; it did not provide accurate information to enable people to make an informed choice. Case records lacked depth and detail to demonstrate that people’s care needs had been fully identified before they moved into the home. EVIDENCE: The amended statement of purpose continues to lack correct information to enable people to be fully aware of the services provided at the home. There was a lack of information describing how the home would meet the needs of all people who live at the home. Information contained within the 3 case files examined wasn’t all recorded appropriately or correctly. Staff agreed that they needed further training to enable them to complete them to the benefit of people who choose to live at the home. DS0000067664.V350496.R01.S.doc Version 5.2 Page 9 Pre-admission assessments required more depth and detail to identify care needs and personal preferences. Some care needs had been identified yet staff had failed to take action to develop a plan for each care problem. This potentially leads to a person’s care needs not being met. There was a lack of clear evidence that each person’s mental capacity had been assessed with suitable persons identified who would ensure that people’s rights were considered and maintained effectively. Staff said that any specialised equipment that may be required is obtained before any person is admitted to ensure people’s health and wellbeing is maintained. Intermediate care is not provided at the home. DS0000067664.V350496.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 and 10. People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Recording and assessment of care has not improved. Some people’s health and safety was being placed at risk. There are omissions on identifying risk, planning care and providing clear guidance for staff. Systems for the ordering, storage and administration of prescribed medication did not fully protect people. EVIDENCE: The case files examined lacked detail of people’s needs and abilities. This had resulted in some people’s care needs not being fully met. The poorly maintained recording system had led to staff confusion with key information and observations being muddled and entered inconsistently. This had led to wound management and episodes of confused behaviour being dealt with inadequately. One relative expressed her concerns that she had found unexplained bruising when she assisted her relative with clothing. There had DS0000067664.V350496.R01.S.doc Version 5.2 Page 11 been no record made of any accident or injury although the bruising appeared to be a few days old. This forms part of the Adult Protection investigation. The manager agreed to investigate and provide a report to the CSCI office. Not all risk assessments had been recorded and evaluated; one had failed to promote a person’s safety. There was no evidence of each person’s mental capacity being assessed with identified persons responsible for ensuring that individual needs were protected and met. The inspector discussed areas where improved detailed comment within daily records would reflect the quantity and quality of service/care provided. Some people had not had their weight recorded due to their inability to use stand on scales. There was written evidence of some consultation and support from Doctors, Community Nurses, Chiropodist, Ophthalmic and Dental care. One person had not been offered early intervention and consultation with their GP this failure had caused additional discomfort and attendance at the local hospital. A community nurse commented that some members of the care team enjoyed and demonstrated a very warm and close relationship with people living at the home. This included therapeutic touch with numerous observed hugs for people. The inspector observed staff knocking on bedroom doors and waiting to be invited in before entering. Staff were observed to interact with people demonstrating empathy for their needs. Specialist equipment had been obtained and used to maintain peoples wellbeing such as pressure relieving mattresses. Relatives spoken with confirmed that they had discussed care plans with staff and were aware that they could have access to them. During the unannounced 3rd October 2007 visit some medicine administration records (MAR) were incomplete and lacked identifying photographs for the person. Staff had identified the need for assessment of their practical abilities this would ensure the safety of people being helped to take prescribed medicines. The CSCI pharmacist undertook an unannounced inspection of the service to look at systems and practices within the home that support the safe handling of medicines. This involved observing medicines administration and looking at medicine policies, MAR charts, stock control records, and storage arrangements. His comments are as follows; DS0000067664.V350496.R01.S.doc Version 5.2 Page 12 What they do well • • Staff provide practical support and give plenty of encouragement to those people experiencing difficulty in taking their medicines. Storage & record keeping arrangements in place for controlled drugs provide the additional security required for this type of medicine. What they could do better • • • The policy should be reviewed to include comprehensive procedures to ensure staff work to current guidance and legislation. There should be systems in place to support people who may wish to manage their own medicines. Staff should always sign & date their own handwritten entries on MAR charts and arrange for them to be checked and countersigned by a witness to reduce the risk of mistakes when copying information from the pharmacy label. All medication should be stored securely and at the temperatures recommended by the manufacturer so that they are safe to use. • During the inspection (15/10/07) we observed staff administering medications and helping people to take their prescribed medicines. Records were correctly maintained. One member of staff has responsibility for ordering and storage of medications, these were stored safely. A fridge for storage of medicines has been ordered, its delivery was expected within the next 3 days. None of the people living at the home was responsible for their own medication although this facility is available. DS0000067664.V350496.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 and 15. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Visitors were welcome and involved in care at the home. Limited opportunities were available for people to participate in stimulating and motivating activities either within or outside the home. The meals provided were of a good standard however lack of a published menu did limit people’s choice. People were encouraged to eat a healthy and varied diet. EVIDENCE: Not all case records had clearly recorded personal histories; the information had been recorded in various areas of the file. It is used to describe people, their lives and interests and include religious and cultural needs to inform basic lifestyle issues such as diet and dress, and how staff, sometimes in conjunction with families act to meet these. People were encouraged to choose their own clothes to wear each day, decide when to bathe, where to sit and select their own meals. DS0000067664.V350496.R01.S.doc Version 5.2 Page 14 The meals served on the day of the inspection were well cooked and well presented. Staff were observed to encourage and assist with meals as needed. Three people were spoken with to ascertain their views about the food. They said they liked the food. Mealtimes were unhurried with extra portions available as required. Portions were adjusted to each person likes and needs. Special diets were available for those requiring this service. People were encouraged to eat healthily. The menu wasn’t readily available there was limited records kept of each persons food consumption. Alternative meals were available if they did not like the planned meal. The home employs an activities co-ordinator. Care staff was observed to organise the limited activities that occurred at the time of inspection. Care plans and daily records did make reference to activities that people had taken part in and their participation such as watching TV, listening to music, trips out with staff, locally to shops and home visits for those people that have relatives living nearby. Management stated that there were shortcomings with the present in-house activities arrangements. DS0000067664.V350496.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 and 18. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home and relatives had received information that would enable them to make a complaint. Complaints received from concerned carers had not been acted upon in an effective or timely manner leading to a lack of confidence in the management and providers ability to provide care and protect vulnerable persons. Staff had received training to respond to any concerns raised; this should increase staff ability to report and respond to any complaints and concerns raised. EVIDENCE: People receive information that would enable them to make a complaint. A relative had raised a number of concerns in respect of both care and services, these were investigated by the home’s management, the local placing authority and CSCI and were substantiated. Additional concerns were raised that people were being woken and made to get out of bed at 04.30am. CSCI and DMBC officers jointly investigated this on behalf of the adult protection team. This was substantiated with immediate requirements made. These were to provide additional staff, strengthen the DS0000067664.V350496.R01.S.doc Version 5.2 Page 16 home’s management, improve recording systems and provide hot water and a suitable warm environment at all times. Staff had recently received training to enable them to recognise potential abuse and protect people who live at the home. There had been a number of situations when the home’s management and staff had failed to act in either a timely or effective manner. Incidents, accidents and complaints have not been properly recorded or notified. Financial records and personal information was insecurely stored. Policies and procedures for management of monies and financial matters do not protect people who live at the home. DMBC has provided additional support to develop safe and accurate systems for managing finances at the home. There was no clear accounting audit trail leaving people at risk of financial abuse. CSCI and DMBC staff are jointly working with the homes management and the management consultant in an attempt to ensure people living at the home can have confidence that the home will protect them from abuse. DMBC continue to restrict admissions to Roman Court until an increasing number of ongoing Adult Protection investigations are concluded. DS0000067664.V350496.R01.S.doc Version 5.2 Page 17 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 and 26. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Roman Court has a homely appearance. There were unpleasant odours in two identified areas. The building had failed to meet some minimum environmental standards for maintenance, decoration and safety of people who live there. EVIDENCE: During the inspectors tour of the building it was clear there had been little progress towards meeting the requirements made in November 2006. Some areas of decoration and the building had visibly deteriorated. Two areas of the home had strong and offensive odours. Areas requiring attention identified included decoration, furnishings and soft furnishings were worn. There was a general lack of maintenance. The home DS0000067664.V350496.R01.S.doc Version 5.2 Page 18 has a dedicated maintenance man whose restricted working hours limit his ability to remedy minor defects promptly. There is a lack of variable height chairs to ensure individual peoples mobility is not restricted or impeded by difficulty getting into and out of chairs. Most bathrooms were dated with basic amenities that lacked homely features. The signs used to guide people to bedrooms; toilets and bathrooms were not suitable for the people who live at the home. Hot water supply to individual bedrooms and constant room temperatures has not been maintained. Improvements to the central supply system are needed to maintain people’s comfort. DS0000067664.V350496.R01.S.doc Version 5.2 Page 19 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 and 30. People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including looking at training and supervision records, speaking to available staff and people who use the service. Staff have continued to endeavour to maintain standards and meet peoples care needs. They lack clear managerial direction, supervision, organisation and training to ensure the health safety and protection of people who live at the home. EVIDENCE: Following the CSCI unannounced visit (as part of the adult protection investigation) the immediate requirement (21st October 2007) for minimum numbers of staff on duty was met. The home’s management has provided some additional training opportunities, these were well received by staff, they were able to describe the skills they had gained such as actions to take in event of a fire being seen or suspected. Over 50 of staff have achieved NVQ work based training and assessments. Staff undertake some domestic duties in addition to their care role, this reduces the opportunities they have to engage in 1:1 activities with people who live at the home. DS0000067664.V350496.R01.S.doc Version 5.2 Page 20 Staff files lacked evidence of statutory checks to protect vulnerable people; some contained completed application forms, references and records of completed training. There were adequate numbers of staff on duty to meet housekeeping, catering and care needs. There was a lack of staff to maintain the building and meet the social needs of people who live at the home. There had been a lack of staff supervision this provides staff with the opportunity to share concerns and be managed effectively in their care delivery. One member of staff was seen to respond poorly to an episode of aggressive behaviour by a confused person. The care plan did not identify the actions staff needed to take clearly. She said she hadn’t been trained to deal with challenging behaviour. There has been few staff meetings these provide communication and support for the staff team and individuals providing care and services at the home. The deputy manager and senior care staff had been poorly prepared for their increased responsibilities. Recent changes had been inadequately communicated. Staff require training and assessment with ongoing development opportunities and supervision to enable them to effectively support the manager and ensure provision of minimum care standards. The maintenance person works 20 hours each week this does not enable him to make progress towards improving the environment for people who live and work at the home. There is no administrative support for the manager this has not enabled the records to be filed in a systematic manner. DS0000067664.V350496.R01.S.doc Version 5.2 Page 21 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 and 38. People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including interviewing the registered manager and observing staff as they work. Staff provide basic care. The home is poorly organised and managed. Monitoring and recording systems are inadequate. They fail to support staff in care delivery, promote individual people’s choice and rights or provide and maintain their health, safety and welfare. EVIDENCE: The home is poorly organised and managed. The organisation and management systems at the home were confused and inadequate, there was a lack of planning, review and audit trails. The record keeping systems were inadequate and leave people who live at the home at potential risk of failure to provide care or potential abuse. DS0000067664.V350496.R01.S.doc Version 5.2 Page 22 The home does not have a registered manager; the acting manager is being supported by a management consultant. Staff provides basic care despite the ongoing failure of the home’s owners and middle management to provide minimal supervision, guidance, support and leadership. Monitoring and recording systems are inadequate. They fail to support staff in care delivery, promote individual people’s choice and rights or provide and maintain their health, safety and welfare. Staff supervision has not been implemented; this ensures that staff has the opportunity for to get feedback from the manager. Staff files lack evidence of Criminal Record Bureau (CRB) and Protection of Vulnerable Adult checks (POVA), these have now been applied for by the management consultant The existing quality assurance system does not enable the company to monitor the quality of services or provide a voice for people who live at the home. There is a lack of regular meetings for families and people who live at the home; this deprives them of a voice in the running and management of the home. Notification of events affecting the wellbeing of people living at the home were not submitted to the local office of the CSCI, this reduces the opportunity for monitoring care and safety of people. This is the subject of an immediate requirement. Staff were seen to be using wheelchairs to move people around the home. Some wheelchairs had their footrests removed; this unsafe practise puts people at risk of injury. Statutory checks gas and electricity supplies/equipment had been completed with service documents available. DS0000067664.V350496.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 2 x x X X X x 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 1 1 x 1 DS0000067664.V350496.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4, 5. Requirement The registered owners must ensure that the Statement of Purpose contains all the requirements contained in Schedule 1 (previous timescale 28/10/07) Pre-admission assessments must be documented to demonstrate that the home is both able to meet a prospective people’s care needs and a plan to meet the identified needs is in place. The registered owners must ensure that reviews of care provided are undertaken at least monthly. The registered owners must ensure that: • Risk assessments must be fully completed. Any identified risks must include clear guidance for staff on how to manage the risk; • Action plans must clearly describe what staff need to do to meet the assessed needs of people; this must include DS0000067664.V350496.R01.S.doc Timescale for action 28/11/07 2 OP3 14 28/11/07 3 OP7 4 28/11/07 5. OP7 15 28/11/07 Version 5.2 Page 25 6 OP7 8(1)a 7 OP12 16(2)m 8 OP7 17(1)a 9 OP9 13(2) individual assessment and identification of the appropriate advocate as required by the Mental Health Capacity Act 2007. • Care plans must be fully up to date and include information about people’s preferred social and leisure activities and how these will be provided. (Previous timescale 28/10/07). People living at the home must be allowed to rise and retire as they wish. Care plans must record these preferences as confirmed verbally during the inspection. Social and recreational activities must be provided for residents in line with their preferences. (Previous timescale 31/01/07). The registered owners must ensure that all people’s weights are measured and recorded at least monthly. The registered person must ensure that: • the medication policy and procedures are revised and expanded so that staff are always working to current good practice guidance; • accurate records are kept of all medicines received, administered, refused and leaving the home or disposed of to ensure medicines are always given as prescribed and that there is no mishandling; • hand-written entries on the MAR charts contain all essential information, are signed & dated by the author, and then checked DS0000067664.V350496.R01.S.doc 28/11/07 28/11/07 28/11/07 31/10/07 Version 5.2 Page 26 10 OP9 13(2) 11 OP15 16(2)(i) 12 OP18 22 13 14 OP26 OP19 23(2)(d) 23(a)(b) 15 OP30 18 & countersigned by a witness to reduce the risk of mistakes when copying information from the pharmacy label; • all medicines are stored appropriately and securely at the temperature recommended by the manufacturer so that they are safe to use. The registered person must ensure that all staff authorised to handle and administer medicines have been appropriately trained and assessed as competent so that they can handle and record medicines safely. A menu should be provided that offers a choice of meals in written or other formats should be given, read or explained to people at the home. Review existing Adult Protection Policy and Procedure to ensure effective robust communication channels and timely responses to any concern raised by each tier of staff and management. The home must be kept clean and free from offensive odours The registered owners must ensure that all areas of the home are kept in a good state of repair both internally and externally and all parts of the home are kept clean and reasonably decorated. (Previous timescale 31/10/07). Staff must be assessed and have an individual training programme compiled. The training must be focussed upon the needs of the people living at the home and include dealing with challenging behaviour, communication skills, health and safety, moving and DS0000067664.V350496.R01.S.doc 30/11/07 30/11/07 28/11/07 28/11/07 28/12/07 28/11/07 Version 5.2 Page 27 16 OP33 24 17 OP33 24 18 OP36 18 19 OP37 17 20 OP37 37 21 OP38 23(2)(j) (p) handling and dementia care. All staff must be suitably qualified, competent and experienced to meet the health, safety and care needs of people. An effective quality assurance and quality monitoring system, based on seeking the views of service users, to measure success in meeting the aims, objectives and statement of purpose of the home must be put in place. Policies and procedures must be reviewed to reflect good practice, including the Metal Health Capacity Act 2007. Previous timescale 30/09/07. The registered owners must ensure that all staff receives formal supervision at least six times a year with a record kept of the agreed content of that supervision. Records must be maintained securely at the home for inspection and avoid breach of confidentiality. Notification of any death, illness and any other event must be made to the CSCI without delay any notification made orally shall be confirmed in writing. Room temperatures must be maintained at a minimum of 21 degrees centigrade. Arrangements must be made to ensure a supply of hot water to bedrooms and bathrooms throughout the home. This should be at a temperature of 43 degrees centigrade; it should be available at all times. Previous timescale 24/09/07 Footrests must not be removed from wheelchairs. 28/11/07 28/11/07 28/10/07 28/10/07 28/11/07 28/11/07 DS0000067664.V350496.R01.S.doc Version 5.2 Page 28 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 OP9 Good Practice Recommendations All staff authorised to handle & administer medicines should indicate that they have read & understood the relevant policy & procedures. MAR chart dividers should be improved in quality and should display a current photograph and other essential information to help ensure medicines are always given to the right person. Senior staff recording monthly medicines received should keep and check a copy of the original prescription to ensure all items requested by the home are accurately prescribed and supplied. The acting manager must register to attain a level 4 NVQ and the registered managers award. Administrative support should be provided to secure and collate personal files and documentation within the main building. 3 OP9 4 5 OP31 OP37 DS0000067664.V350496.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000067664.V350496.R01.S.doc Version 5.2 Page 30 - 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!