Inspection on 24/05/07 for Brendoncare Ronald Gibson House

This inspection was carried out on 24th May 2007.

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

Brendoncare Ronald Gibson House 19/06/08

Brendoncare Ronald Gibson House 29/08/06

Brendoncare Ronald Gibson House 17/01/06

Brendoncare Ronald Gibson House 19/04/05

Brendoncare Ronald Gibson House 23/11/04

Brendoncare Ronald Gibson House 15/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Ronald Gibson House 236 Burntwood Lane Tooting London SW17 0AN Lead Inspector Sharon Newman Unannounced Inspection 24th May 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ronald Gibson House DS0000019116.V339117.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. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ronald Gibson House Address 236 Burntwood Lane Tooting London SW17 0AN 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) 020 8877 9998 020 8877 3860 mbird@brendoncare.org.uk www.brendoncare.org.uk The Brendoncare Foundation Ms Heather Butler-Gallie Care Home 56 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (16), Learning disability (2), Old age, not falling of places within any other category (56) Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Management of the home There will be a total of 56 management hours per week available within the Home. The Manager of the Home will remain supernumerary and work full-time. The balance of the 56 hours will be provided by designated staff. Care Staff and Dementia Unit Care staff must be provided in sufficient numbers, and with the necessary qualifications and experience, to meet the assessed needs and dependency levels of all low, medium, high, and continuing care band service users accommodated in the Home at any one time. As a minimum care staff shall be provided as follows : 8am to 2pm : 2 Registered Nurses 8 Care Assistants 2pm to 8pm : 2 Registered Nurses 7 Care Assistants 8pm to 8am : 2 Registered Nurses 3 Care Assistants The specified registered nurse numbers are additional to the supernumerary management hours set out above. the low, medium and high bands refer to assessments for Registered Nursing Care Contributions (RNCCs). The continuing care band applies to service users whose needs are predominantly for health care, and who are therefore wholly funded by the NHS Ancillary staff for all units There will be adequate and sufficient staff and/ or contract arrangements in place at all times to ensure a good quality catering, domestic, cleaning, laundry, maintenance, and administrative service for all users. Respite Care Respire Care agreed for one specified female service user who is under 55 years of age. One male service user aged 48-55 requiring general nursing care 0ne Service user aged 53-65, with Dementia, can be accommodated within the home Two Service users aged 53-65, with Learning disabilities, can be accommodated within the home 2. 3. 4. 5. 6. 7. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 5 Date of last inspection 18th January 2007 Brief Description of the Service: Ronald Gibson House provides nursing care and accommodation for 56 residents, 20 of whom may have dementia. The service is organised on two floors with one unit providing dementia care being located on the ground floor. The home is operated by the Brendoncare Foundation and is situated near Springfield Hospital in Tooting. There is sufficient parking on site for visitors and the home has access to local bus routes. The range of fees at the time of inspection range from £752.50-£845.00 per week, depending on care needs. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. Two regulation inspectors and a pharmacy inspector visited the home on the 24th May 2007. The manager was not on duty on the day of inspection as he is on long-term leave. The inspection team spoke to residents and staff on duty. Documentation looked at included medication records, staff recruitment information, residents care plans and health and safety documentation. A tour was also taken of the premises. An Annual Quality Assurance Assessment (AQAA) has been sent to the home for them to complete and return, this is a self assessment survey. However this did not arrive prior to completion of this report. The pharmacist will send out a separate report with their findings. Surveys were left at the home for residents, staff, relatives and health professionals to complete. None were returned before this report was completed. A relative commented that ‘they had nothing but praise’ for the home. What the service does well: What has improved since the last inspection? The conservatory is now used as a dining room and creates a pleasant atmosphere for residents to take their meals in. Drinks dispensers are now available for residents in the lounge areas so that they have a choice of cold drinks. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 7 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 Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ronald Gibson House DS0000019116.V339117.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 Ronald Gibson House DS0000019116.V339117.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 good This judgement has been made using available evidence including a visit to this service. Residents are assessed before they are admitted to the home. This helps to make sure that the home can meet their needs. EVIDENCE: A combined Statement of Purpose and Service Users Guide is in place. This contains information about the environment, dignity, the admission policy, fees, finances, complaints and protection and resident’s rights. Prior to coming to this home prospective residents are assessed by a social worker. They also have a ‘nursing needs’ assessment to determine whether they have nursing care needs. The inspection team were informed that the majority of residents at the home require a high level of care. The home has provided a sensory room and garden and an activities room to help meet the needs of the residents. They have also employed a nurse who is Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 11 specifically trained to meet the needs of residents with mental health issues. A physiotherapist, activities co-coordinator and sensory worker are employed by the home. A family member reported that their relative was ‘extremely well looked after here.’ They said that they visit daily and have lunch with their relative. They commented ‘I can’t speak too highly of the home.’ Ronald Gibson House DS0000019116.V339117.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, 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments do not all contain enough detailed information to demonstrate that residents needs can be fully met. People who use the home have access to health care services. EVIDENCE: The care plans were seen to contain comprehensive information about residents health and social needs. However, although some of the care plans demonstrated a more person centred approach, others did not and were more task orientated. There was also little evidence that residents or their relatives had been involved in the care planning process. All care plans need to consistently show evidence of person centred planning to help ensure that resident’s needs and wishes are taken into consideration. A ‘long term assessment and care plan’ is in place and contains information about eating and drinking, personal cleansing, vision, hearing and oral care. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 13 However, this information is not detailed enough in many cases, for example entries stated: ‘doubly incontinent’ and ‘needs assistance with personal hygiene.’ In each case the information is not expanded upon and there is no indication of what assistance is needed. More detail is needed to help make sure that resident’s needs can be met. Some of this documentation was not signed or dated by the staff member completing it. Staff must ensure that they sign and date all assessments and care plans. The key worker recording sheets also need to contain more detail. They contained comments such as ‘assisted with personal care’ and ‘personal hygiene needs met’ but did not state what care had been carried out. There is a range of assessments and risk assessment documentation in place for areas including: pressure areas, nutrition, falls and mobility and impaired memory. Some of these assessments were detailed and contained useful and relevant information about the residents needs. A nutritional risk assessment was seen to have been reviewed and appropriate action taken. However, another nutritional assessment seen did not contain any reference to the percutaneus endoscopic gastronomy (peg) feeding that a resident was receiving. The assessments must contain all the relevant information about a resident to ensure that their needs can be met. Pressure sore risk assessments were in place but in some cases where a high risk has been identified there was no evidence of any action taken. One entry stated that a resident ‘had a waterlow score of 30, therefore’ they were ‘at high risk.’ It did not then specify what action had been taken to address this. Risk assessments need to contain more detail to demonstrate that the appropriate action has been taken. Continence assessments were not in place in the residents files seen even though their assessments stated that they had continence issues. Resident’s continence needs must be assessed by an individual trained to carry out such an assessment. This is to ensure that residents needs can be met. Where the need for bed rails, wheelchairs and wheelchair straps had been identified, some of the agreements seen were signed by residents or relatives to demonstrate their agreement. However, this was not the case in all the files looked at. Where any equipment such as this is needed then agreements must be in place signed by residents or relatives. Risk assessments should demonstrate the involvement of the residents, health and social care professionals involved in their care as well as their family if they wish. This helps to demonstrate that the decisions have been taken in the best interests of the resident and with their agreement. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 14 Details of the type of hoist and sling used to move residents was not found in care plans and this information must be recorded to help ensure the health and safety of residents. There was evidence in the care plans of input from health and social care professionals including: GP’s, specialist nurses and dentists. Residents wishes regarding end of life care and death and dying were not completed in sufficient detail to ensure that their wishes will be met. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships. Staff are sensitive to the needs of those residents who find it difficult to eat and give assistance at mealtimes. Meals are taken in a relaxed and unhurried environment ensuring that it is a pleasant experience for residents. EVIDENCE: The physiotherapist was spoken to during this visit. They had a very good knowledge of the residents and their needs and is very committed to providing a high level of care. Daily activities were observed to be taking place in the ‘activities’ room, where the residents had been joined by a visiting cat which they all enjoyed. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 16 There is also a ‘sensory room’ at the home, which is spacious and welldecorated. The physiotherapist said residents come in here to just relax or to take part in activities designed to stimulate their senses. The room has a calm feel with low lighting and a range of different light sources and a water feature. Aromatherapy is offered to residents and an ‘aromatherapy intervention plans’ was seen in the residents files. Residents daily activities were not seen to be fully recorded in their care plans and staff must be encouraged to do this to demonstrate what activities the residents have been involved in. Residents were observed to choose to go and sit or walk in the gardens . Some residents were taken into the gardens in their wheelchairs accompanied by staff members. Visitors were seen to be welcomed and privacy respected as there is enough space at the home for residents to talk in private to their relatives. A range of television and music equipment is available for residents use in the lounges areas throughout the home. Lunch was seen to be taken in a calm, unhurried atmosphere in the dining areas throughout the home. Background music was played and tables were laid in an attractive manner and brightly coloured crockery was used. This helped create a pleasant atmosphere. Residents needing help were supported to eat their lunch in a dignified manner by staff members who sat beside them to offer assistance. Relatives were seen to sit with their family members and have lunch with them. Staff reported that there has been an issue with unmarked laundry at the home. A large amount of clothing was seen in the laundry room and as it is unmarked staff do not know which residents to return the items to. It is recommended that a system for marking clothed for identification purposes is put in place. Ronald Gibson House DS0000019116.V339117.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 adequate. This judgement has been made using available evidence including a visit to this service. Complaints are not all appropriately logged and there is insufficient evidence to show what outcome was reached. Residents may be placed at risk due to inadequate recording of important information in accidents logs and in the care plans. Protection of vulnerable adult procedures are not always followed. Not all staff are up-to-date with training in the protection of vulnerable adults. EVIDENCE: A complaint was seen to be recorded in a staff members recruitment file but there was no record of this in the complaint log. A further issue recorded in a residents care plan had also not been documented in the complaint log. Also, complaints documented in the log did not have details of the action taken or outcome. All complaints need to be fully logged and the outcomes recorded to ensure that this process is fair and transparent. Incidents/accidents recorded in the accident log indicated that residents have occasionally sustained unexplained injuries or bruising and self inflicted injuries due to their level of confusion. There was no evidence that medical intervention had been sought or of any follow up. All incidents of unexplained Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 18 bruising or injury must be referred to the London Borough of Wandsworth following their Protection of Vulnerable Adult Procedures. All bruising and injuries must be fully documented and the appropriate advice must be sought from a healthcare/medical professional. There was insufficient evidence at the time of inspection to demonstrate that all staff are up-to-date with training in abuse awareness and the protection of vulnerable adults, this needs to be put in place to ensure that residents are not pace at risk. Ronald Gibson House DS0000019116.V339117.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 excellent. This judgement has been made using available evidence including a visit to this service. The home is well decorated and has a relaxed feel. The furniture is sturdy and attractive and the pictures and plants help to create a homely atmosphere. It is clean and hygienic. EVIDENCE: The grounds and gardens are spacious and it is evident that these areas have been given a lot of thought by the organisation. There are a variety of ornamental features, raised flower beds and seating arrangements throughout the garden. All the garden areas are well-maintained with many flowers planted throughout. Residents are free to use them when they wish and were seen to be sitting and relaxing outside. Staff were observed to take residents out into the garden in their wheelchairs. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 20 The dementia unit is well furnished and has it’s own garden. There are fish tanks and plants throughout the home which helps to create a very pleasant ambience. Drinks dispensers are available for residents to help themselves to cold drinks. The bedrooms were seen to be clean and personalised with ornaments, photographs and pictures. There is a well-equipped ‘sensory’ room and an activities room which both lead out into the garden. The home was clean, hygienic and free from unpleasant odours on the day of inspection. There were notices regarding the importance of hand washing throughout the home and hand washing facilities are provided. Ronald Gibson House DS0000019116.V339117.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. There is not enough evidence of up-to-date staff training which could have an affect on the care of the residents. There is not enough evidence to show that pre-employment checks are in place to help protect the residents from harm. EVIDENCE: The inspection team were informed that the home operates with a team leader, three registered nurse and twelve care staff for the morning shift. In the afternoon a team leader and registered nurse are on duty with ten care staff. The night shift consists of two nursing staff and six care staff. A team leader reported that these staffing levels meet the needs of the residents. Sufficient staff were seen to be on duty on the day of inspection. The staff recruitment files looked at during this visit require re-organisation. It was difficult to find relevant information, they were poorly organised and many loose pages fell out of the files. Some information was missing from the files looked at. Colour photographs of the staff members were not found in all the staff files looked at. These need to be in place for identification purposes. Two of the files looked at did not contain two references. This information needs to Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 22 be in place before staff start to work at the home to help to ensure that residents are not placed at risk. There was insufficient documentation to show that all staff are up-to-date in with training in areas such as food hygiene and the protection of vulnerable adults (POVA). All staff need to be up-to-date in these areas to help ensure that residents are not placed at risk. There is a staff training programme in place for moving and handling. However, poor moving and handling practice was observed during the inspection as a resident was transferred manually from a wheelchair into a chair. All staff must put into practice the moving and handling training that they have been given. This is to ensure that residents and staff are not placed at risk. A relative commented that ‘the staff are brilliant.’ Ronald Gibson House DS0000019116.V339117.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, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff do not currently have the support they need to carry out their roles due to a lack of one-to-one supervision. EVIDENCE: The inspection team were informed that the manager has been on a period of extended leave. An interim service manager is offering support to the home and was not available on the day of inspection. The manager is still not registered with the Commission for Social Care Inspection and will need to do so. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 24 Staff one-to-one supervision is taking place but the frequency needs to increase and this was discussed with staff on the day of inspection. This is to help ensure that staff have the direction and support that they need to carry out their roles. And for any training and development needs to be identified. There was insufficient evidence to demonstrate that care staff meetings are taking place frequently enough and this was discussed with a staff member during the inspection. The frequency of these meetings must increase to ensure that staff are kept up-to-date with developments at the home and have an opportunity to raise any issues. Several instances were recorded in the home’s ‘accident log’ where the Commission for Social Care Inspection (CSCI) had not been informed of events that affected the well being of residents. The Commission for Social Care Inspection (CSCI) must be notified of all events that affect the well-being and safety of the residents. An up-to-date gas safety or portable appliance testing certificate could not be found on the day of inspection and this needs to be addressed. However, other checks relating to safety including: legionella, lift servicing and electrical installations were up-to-date. The fire detection and fire alarm systems have both been serviced. Ronald Gibson House DS0000019116.V339117.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 3 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Ronald Gibson House DS0000019116.V339117.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 OP7 Regulation 15 (1) (2) (c) Requirement Care plans need to be more person centred. Residents must be involved in the care planning process. This is to help demonstrate their agreement to their care and to ensure that all their health and social needs are taken into consideration. Plans must be signed by the service user (or if necessary their representative) as an indication of their agreement. Care plans and risk assessments must be signed and dated by the staff members completing this documentation. Details of the type of hoist and sling used to move residents must be detailed in care plans. Previous timescale of 30/03/07 not met. Specific risk assessments for wheelchair use and straps must be in place and completed fully. Risk assessments must demonstrate the resident’s right to take appropriate risk. They must show the involvement of the residents and their relatives DS0000019116.V339117.R01.S.doc Timescale for action 01/08/07 2 OP7 15 (1) (2) 01/08/07 3 OP7 13 (4) (b) 01/08/07 4 OP8 12 (2) 01/08/07 Ronald Gibson House Version 5.2 Page 27 5 OP8 12 (2) 6 7 OP8 OP11 13 (1) (b) 12 (2) 8 OP12 16 (2) (m) 9 OP16 22 10 OP18 13(4&6)1 8(1)c 11 OP18 13 (4) (6) 12 OP29 19 (4) (a) (b) Schedule and of the appropriate health and social care professionals. Specific risk assessments for the use of bed rail equipment must be in place and completed fully. Risk assessments must demonstrate the resident’s right to take appropriate risk. They must show the involvement of the residents and their relatives and of the appropriate health and social care professionals. Specific assessments must be in place for continence needs and must be completed fully. Residents’ wishes with respect to end of life care and death and dying must be documented and respected. Previous timescales of 30/11/06 and 30/03/07 not met Activities undertaken by residents must be recorded daily. Previous timescale of 30/03/07 not met. All complaints must be fully recorded with details of the action taken and the outcome. This is to ensure that this process is clear and transparent. All staff must be trained in recognising and reporting abuse. Previous timescales of 01/06/05, 01/11/05, 01/08/06 and 01/12/06 not met Where residents have sustained injuries or bruising these must be fully documented and the appropriate health and social care professionals must be informed. Appropriate medical advice must be sought immediately and fully documented. Staff recruitment files contain the necessary pre-recruitment information. This is to help DS0000019116.V339117.R01.S.doc 01/08/07 01/07/08 01/08/07 01/08/07 01/07/07 01/07/07 24/05/07 01/07/07 Ronald Gibson House Version 5.2 Page 28 2 13 OP30 18 (1) 13 (4) (5) 14 OP30 13 (5) 18 (1) (c) 15 16 OP31 OP33 8 37 17 OP36 18(2)a 18 OP38 13 (4) 19 OP38 13 (4) ensure the safety of the residents. There must be clear evidence that mandatory staff training is up-to-date. Refresher training must be provided for staff as required including food hygiene. Moving and handling training must be put into practice at all times. This is to make sure that residents and staff are not placed at risk of injury. Previous timescales of 30/11/06 and 30/03/07 not met. The manager must register with the Commission for Social Care Inspection. The Commission for Social Care Inspection must be notified of all events that affect the well being and safety of the residents. All staff must receive one-to-one supervision at least six times a year (pro-rata for part time staff) and this must be fully recorded. 01/12/06 An up-to-date portable appliance test must be carried out to help ensure the safety of staff and residents. An up-to-date gas safety test must be carried out to help ensure the safety of staff and residents. 01/07/07 01/07/07 01/09/07 01/07/07 01/08/07 01/08/07 01/08/07 1 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 The home should consider labelling residents laundry to DS0000019116.V339117.R01.S.doc Version 5.2 Page 29 Ronald Gibson House ensure it is returned to the correct individual. Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Ronald Gibson House DS0000019116.V339117.R01.S.doc Version 5.2 Page 31 - 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!