Inspection on 10/05/07 for Rosemead Care Home

This inspection was carried out on 10th 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

Rosemead Care Home 28/04/10

Rosemead Care Home 10/08/09

Rosemead Care Home 07/11/06

Rosemead Care Home 14/06/06

Rosemead Care Home 06/09/05

Rosemead Care Home 07/04/05

Rosemead Care Home 29/09/04

Rosemead Care Home 27/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Wynthorpe Rest Home, 10-12 Rectory Road Walthamstow London E17 3BQ Lead Inspector Rob Cole Key Unannounced Inspection 10th May 2007 10:00 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 DS0000007217.V339257.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. DS0000007217.V339257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wynthorpe Rest Home, Address 10-12 Rectory Road Walthamstow London E17 3BQ 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 8520 6027 F/P 020 8520 6027 Mr Saeed Ahmed *** Post Vacant *** Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places DS0000007217.V339257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Wynthorpe Rest Home is registered to provide support and accommodation to fourteen service users over the age of sixty five. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, and is close to shops, transport links and other local amenities. The home consists of two houses that have been converted in to one, and is built over two floors. The home is privately run. DS0000007217.V339257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 10/5/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes acting manager was present throughout the course of the inspection. The inspection also included a tour of the premisis, and an examination of records and documents. Overall, despite some limited improvements since the last inspection, there still remains much to be done before the home is operating fully in line with National Minimum Standards and the Care Homes Regulations 2001. A total of twenty five requirements have been made in this report, fifteen of which are repeated from the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements there is still much that must be improved. The home must appoint a permanent manager who is put forward for registration with the CSCI, and ensure that they are given sufficient time to carry out all required management duties. Staffing levels must be reviewed, to determine how the home can meet the assessed needs of all service users, and the home must implement an emergency on-call procedure. Care plans and risk assessments must be produced to a consistently detailed and comprehensive standard. DS0000007217.V339257.R01.S.doc Version 5.2 Page 6 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. DS0000007217.V339257.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 DS0000007217.V339257.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): 1,2,4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was not satisfied that prospective service users are provided with sufficient information about the home before making a decision as to move in or not. Prospective service users must be able to visit the home, and written documentation about the home must be up to date. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Although the Statement of Purpose has been reviewed since the previous inspection, it still contains inaccurate information, for example is states that the home has domestic cleaning staff and a cook, while in fact these domestic duties are carried out by the care staff. The Statement does include information on the services and facilities provided by the home. The Service DS0000007217.V339257.R01.S.doc Version 5.2 Page 9 User Guide has not been reviewed since 2003, and as with the statement, contains inaccurate information, for instance the details of the manager are for someone who left the home over a year ago. It is required that both the Statement of Purpose and Service User Guide are subject to regular review, and that they contain accurate and up to date information. Individual contracts/statement of terms and conditions were in place for service users. Those examined by the inspector contained all necessary information in line with National Minimum Standards (NMS). There have been no new admissions to the home since the previous inspection, although the home does currently have some vacancies. The acting manager talked the inspector through their understanding of the admissions procedure. They informed the inspector that they would carry out pre admission assessments, and invite the prospective service user to the home to see if they liked it, before making a decision as to move in or not. However, the homes admission procedure made no mention of either pre admission assessments, or of the opportunity of visiting the home before moving in. It is required that service users are able to visit the home, prior to admission, and that the homes admission procedure accurately reflects the actual practice of admissions. DS0000007217.V339257.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector believes that the home is generally able to meet the health and personal care needs of service users, although care plans and risk assessments must be more comprehensive. EVIDENCE: Care plans were in place for all service users. The home has recently introduced a person centred plan for one service user, which was of a good quality. This has been drawn up with the involvement of the service user, their keyworker and the homes manager. This plan was clear and comprehensive. It was easy to understand, and gave sufficiently detailed information about the service user to enable the home to understand and meet their needs. The acting manager informed the inspector that it was planned that this format of care planning would be introduced for all service users. It was however noted DS0000007217.V339257.R01.S.doc Version 5.2 Page 11 that the standard of care plans for the remaining service users was very basic. For example, some service users have a diagnosis of dementia, yet care plans did not include any information about this. Further, plans have not been subject to regular review. One care plan dated 2005 stated that the service user should be supported with knitting, but the acting manager said this was no longer applicable, although the care plan had not been changed to reflect this. It is required that clear and comprehensive care plans are in place for all service users, and that these are subject to regular review, at least once a month. As with care plans, the hone has introduced a new format of risk assessments for one service user, but not for the others. The new assessment is of a satisfactory standard. It includes risks around falling and choking, and includes strategies to manage and reduce any identified risks. However, for the other service users risk assessments are not so comprehensive, and some have not been reviewed since November 2005. It is required that clear and comprehensive risk assessments are in place for all service users, and that these are subject to regular review. Two risk assessments identified that the service users were at risk of wandering from the home and getting lost in the community, yet the home did not have a missing persons procedure in place, and this must be addressed. All service users are registered with a GP. Records are maintained of medical appointments, including any follow up action required. These indicated that service users have access to relevant health professionals as appropriate, including dentists, opticians and audiologists. Used continence products are disposed of appropriately. The home has a medication policy in place. Medications are stored in a locked cabinet. No service users self medicate, or are on any controlled drugs. With the exception of the acting manager, all staff with responsibility for administering medications have undertaken appropriate training. However, the acting manager last had medication training six years ago, five years before they joined the Wynthorpe staff team, even though they have responsibility for administering medications. It is required that all staff who administer medications first undertake appropriate training. Medication Administration Record charts are maintained, those checked by the inspector were accurate and up to date. Guidelines were in place for the administration of medications prescribed on a PRN basis. Through observation and discussion there was evidence that the home respects the privacy of service users. Staff were observed to knock on bedroom doors and wait for an answer before entering. Service users are given their own mail to open, and have access to use a telephone in private if they so wish. DS0000007217.V339257.R01.S.doc Version 5.2 Page 12 The acting manager informed the inspector that service users could remain in the home with a terminal illness, as long as the home was able to meet their medical needs. The home has sought the views of some service users on their wishes for arrangements to be made in the event of their death, but not for all service users, and this must be addressed. DS0000007217.V339257.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users have control over their daily lives, and that food is of a satisfactory standard. EVIDENCE: The inspector was pleased to note that the home has recently introduced service user meetings. Minutes from these meetings indicated that service users would like the opportunity of going out into the local community, to visit shops, pubs and daytrips to Southend. However, as yet these outing have not been arranged, and it is required that the home supports service users to access the local community, in line with their assessed needs and stated preference. One service user goes to church weekly. With the exception of visiting the community, there was evidence that service users have control overt their daily lives, for example when to get up and go to DS0000007217.V339257.R01.S.doc Version 5.2 Page 14 bed, and what to wear etc. Since the last inspection all communal areas of the home, including the garden, are now accessible to service users. The home has a visitor’s policy in place, and visitors are welcome at any reasonable time. Service users can see visitors in private if they so wish. The inspector was pleased to note that the overall quality of food provided in the home has improved considerably since the previous inspection. The menu is now more varied, and service users have been involved in planning new menus. Fresh ingredients are now regularly used, as opposed to predominantly tinned and frozen food, and fresh fruit was available on the day of inspection. Service users spoken to informed the inspector that they were happy with both the quality and quantity of food provided. Staff were observed to offer drinks and snacks to service users throughout the course of the inspection. The kitchen was clean and tidy, and food was stored appropriately. Fridge and freezer temperatures are checked daily. DS0000007217.V339257.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that to help ensure service users are safeguarded from the risk of abuse, the homes policy on adult protection must be in line with current legislation. EVIDENCE: The home has a complaints procedure in place. This includes timescales for responding to any complaints received, and since the last inspection now also includes contact details of the CSCI. The procedure was on display within the home. The home also has a complaints log, this evidenced that complaints have been recorded and investigated as appropriate. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. However, as at the previous inspection, this was not in line with current legislation. For example, it does not make clear that the Local Authority has responsibility for deciding who carries out any investigations into allegations of abuse, the homes policy suggests that the proprietor will carry out any such investigation. All staff have undertaken training in adult protection issues, and staff spoken to on the day of inspection DS0000007217.V339257.R01.S.doc Version 5.2 Page 16 demonstrated a good understanding of their roles and responsibility with regard to adult protection issues. DS0000007217.V339257.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): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is able to meet its stated purpose with regard to its physical environment. Service users are provided with adequate communal and private space, and the home was generally well maintained. EVIDENCE: The home is situated in a quiet residential area of Walthamstow in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities. The home is built over two floors, and comprises of two houses that have been converted into one, and is in keeping with other homes in the area. The home was generally well maintained both internally and DS0000007217.V339257.R01.S.doc Version 5.2 Page 18 externally. Fixtures and fittings in communal areas were well maintained, and furniture was domestic in character. Communal areas consist of a sitting room, a sitting room/dining area, a conservatory, a kitchen and a garden, with appropriate garden furniture. The garden was well maintained, and service users were free to move around communal areas. It was however noted that several tiles above the kitchen sink were cracked, and these must be replaced. The home is registered for fourteen service users, and has twelve single bedrooms, and one double bedroom. Two bedrooms are ensuite, all the others have hand basins fitted. Bedrooms meet NMS on size requirements. Bedrooms have been personalised to service users individual tastes, for example with family photographs. Bedding, carpets and curtains were sufficiently well maintained, and domestic in character. Bedrooms contained appropriate furniture, including chest of draws, wardrobes and table and chair. Central heating was provided in all bedrooms, this was appropriately boxed in. Bedrooms had adequate natural light and ventilation. The inspector was satisfied that the home has adequate numbers of toilets and bathing facilities to meet service users needs. Bathrooms were clean and tidy, and free from offensive odours. All had working locks fitted, however, the lock on the ground floor bathroom did not have a working emergency override device, and this must be addressed. The home has various adaptations in place, for example baths have been adapted to make them accessible to all service users, and grab rails have been fitted in toilets. The home has a stair lift between the two floors. The home has laundry facilities that are appropriate in scale to meet service users needs, and hand washing facilities are situated around the home. Protective clothing such as gloves and aprons are made available to staff to help prevent the spread of infection. However, cleaning products were found to be stored in the downstairs bathroom, and it is required that all COSHH products are stored securely. DS0000007217.V339257.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The inspector believes that service users would benefit from higher staffing levels, and that staff must receive all appropriate health and safety training. EVIDENCE: The home provides 24-hour support including a waking night staff. However, the acting manager informed the inspector that the home does not have an emergency on-call procedure, and this must be addressed. At the time of inspection, staffing levels were two care staff on the early shift from 8am to 3pm, plus the manager from Monday to Friday, and two care staff on the late shift from 3pm to 10pm, and one waking night staff and one sleeping night staff. The home does not employ any designated cooking or cleaning staff, care staff are expected to carry out these duties. Although the home is registered for fourteen service users, at the time of inspection only six service users were resident. Nevertheless, the inspector has concerns that staffing levels are not adequate to meet all service users needs. Although the inspector was satisfied that current staffing levels do not pose a significant DS0000007217.V339257.R01.S.doc Version 5.2 Page 20 safety risk to service users, they give staff very little opportunity for meaningful interaction with service users. All service users need one to one support with their personal care, in addition, as mentioned care staff are expected to carry out all cleaning and cooking duties, as well as laundry, administering medication, dealing with phone calls and visitors to the home, paperwork and supporting service users with any appointments they may have. The acting manager informed the inspector that when they were on duty, they were expected to be involved with the care of service users, and did not have sufficient time to deal with administrative and management issues. Both the acting manager and care staff informed the inspector that they believed service users would benefit from extra staffing. At the last inspection a requirement was made that the home conducts a review of staffing levels to determine if current levels were adequate, this was found to be unmet and is repeated in this report. However, it was positively noted that staff on duty had built up good relations with individual service users, and were observed to interact with them in a friendly and positive manner. Staff spoken to demonstrated a good understanding of individual service users needs. The home has policies in place on equal opportunities and recruitment and selection. The inspector checked several staff employment files at random. All contained required documentation, including CRB checks, references and proof of ID. At the previous inspection a requirement was made that all staff receive a thorough induction training on commencing work at the home, in line with the homes Statement of Purpose. As there have been no new staff recruited to the home since the previous inspection, this was not tested on this occasion, but will be tested as part of the next inspection. Of the ten care staff employed at the home, only three have attained an NVQ Level 2 in Care or equivalent qualification (although the inspector was informed that five further staff are currently working towards such a qualification), and it is required that 50 of all care staff are suitably qualified. Recent staff training has included infection control, adult protection and medication. The inspector was pleased to note that since the previous inspection several staff have now had training in dementia. However, not all staff have had all required statutory health and safety training, including fire safety training, and this must be addressed. DS0000007217.V339257.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): 31,33,35,36,37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has not had a permanent registered manager in place for over a year, and the inspector believes that this has impacted detrimentally on the overall quality of care and support provided. EVIDENCE: The home has an acting manager in place. At the time of inspection it was over a year since the home had a permanent manager in place. The acting manager said that it was planned that they would be applying to be registered with the CSCI in the near future. The acting manager informed the inspector that they DS0000007217.V339257.R01.S.doc Version 5.2 Page 22 have insufficient time to carry out all of their administrative and management functions. It was noted that a large number of repeat requirements have been made in this report, and it is required that the home appoints a suitably experienced and competent permanent manager who is then put forward for registration with the CSCI, and that they are given sufficient time to carry out all necessary management duties. Copies of previous inspection reports were available to view in the home, and there was evidence of monthly unannounced Regulation 26 visits taking place. However, there was no system in place for seeking the views of service users on the running of the home, and it is required that the home introduces a system of routinely seeking the views of service users on the running of the home to help inform future planning. The home keeps money on behalf of three service users in a pooled bank account. Since the previous inspection records are now available to indicate how much money each individual has within that account. However, there was no evidence that service users receive any income generated from their individual savings, and there were no records available for inspection on what staff spent money on, on behalf of the service users. Both of these issues must be addressed. Formal one to one staff supervision is very infrequent. Records indicated that one member of the staff team has not had any formal supervision at all in the past year, while another member of the staff team has had only one formal supervision session in the past year. It was further noted that where supervision has taken place, staff are not given a copy of the notes from the supervision. Record keeping within the home was generally of a poor standard. Risk assessments, care plans etc were not kept up to date and fully comprehensive, and it is a repeat requirement that the home maintains all necessary records in line with NMS. Records were however stored securely. Fire extinguishers were situated around the home, and last serviced in August 2006. Fire exits were clearly signed and free from obstruction. Fire alarms are tested weekly, and were last serviced on the 15/3/07. The home holds regular fire drills. The home tests fridge and freezer temperatures and hot water temperatures. There were in date safety certificates for PAT testing and electrical installation, but not for gas safety, and it is required that the home has a gas safety check carried out at least once every twelve months. The home had in date employer’s liability insurance cover in place. There was an inspection of the premisis carried out by the Local Authorities Environmental Health Department on the 21/2/07. Several requirements were made as a result of that visit, that were unmet at the time of this inspection. It DS0000007217.V339257.R01.S.doc Version 5.2 Page 23 is required that the home complies with all requirements made by the Environmental Health Department. DS0000007217.V339257.R01.S.doc Version 5.2 Page 24 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 3 X 3 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 17 X 18 2 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 1 2 2 DS0000007217.V339257.R01.S.doc Version 5.2 Page 25 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 13 Requirement The registered person must ensure that risk assessments are undertaken for safe working practices and for service users undertaking any activities that involve risk taking. The risk assessments must be placed on service users files and be subject to regular review. (Timescale 31/03/07 not met) The registered person must ensure that the home provides appropriate social and leisure activities in line with service users assessed needs and stated preferences including access to the local community. (Timescale 31/03/07 not met) The registered person must ensure that all staff receive statutory health and safety training. (Timescale 31/03/07 not met) The registered person must ensure that staff receive regular formal supervision, at least six times a year, and that a written record is maintained of this supervision, and that staff get a DS0000007217.V339257.R01.S.doc Timescale for action 30/06/07 2. OP12 16 30/06/07 3. OP30 13 30/06/07 4. OP36 18 30/06/07 Version 5.2 Page 26 5. OP1 4 and 6 6. OP7 15 7. OP18 13 8. OP28 18 9. OP30 18 10. OP31 8 11. OP37 17 copy of their own supervision record. (Timescale 31/03/07 not met) The registered person must ensure that the homes Statement of Purpose and Service User Guide are in line with National Minimum Standards and the Care Homes Regulations 2001, and that they are dated and subject to regular review. (Timescale 31/03/07 not met) The registered person must ensure that clear and comprehensive care plans are in place for all service users, and that they are subject to regular review, at least once a month. (Timescale 31/03/07 not met) The registered person must ensure that the home has its own policy and procedure on adult protection, and that this is in line with current legislation. (Timescale 31/03/07 not met) The registered person must ensure that at least 50 of the care staff employed at the home have obtained a relevant care qualification. (Timescale 31/03/07 not met) The registered person must ensure that all staff undertake a structured induction training programme on commencing work at the home, in line with the homes policies and procedures. (Timescale 31/03/07 not met) The registered person must appoint a suitably qualified and experienced permanent manager to the home, and apply for their registration with the CSCI. (Timescale 31/03/07 not met) The registered person must ensure that the home maintains DS0000007217.V339257.R01.S.doc 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 Page 27 Version 5.2 12. OP27 18 13. OP35 13 14. OP35 13 15. OP38 13 16. OP5 12 17. OP7 13 18. OP9 13 19. OP11 15 all necessary records, policies and procedures, as required by the National Minimum Standards and the Care Homes Regulations 2001. (Timescale 31/03/07 not met) The registered person must carry out a review of staffing levels to determine how the home can meet the assessed needs of service users at all times. (Timescale 31/03/07 not met) The registered person must ensure that clear systems are in place to demonstrate what service users personal individual money is spent on. (Timescale 31/03/07 not met) The registered person must ensure that service users receive any income generated from their personal savings, and that the home is able to demonstrate this with clear records. (Timescale 31/03/07 not met) The registered person must ensure that all COSHH products are stored securely. (Timescale 31/03/07 not met) The registered person must ensure that the homes admissions procedure makes clear that service users will be given the opportunity of visiting the home prior to making any decision as to move in or not. The registered person must ensure that the home has a missing persons procedure in place. The registered person must ensure that all staff undertake appropriate training around medications, before they are able to administer any medications within the home. The registered person must ensure that the home seeks and DS0000007217.V339257.R01.S.doc 30/06/07 30/06/07 30/06/07 30/06/07 31/07/07 31/07/07 31/08/07 31/07/07 Page 28 Version 5.2 20. 21. OP19 OP21 23 13 and 23 22. OP27 18 23. OP33 24 24. OP38 13 and 23 25. OP38 13 and 23 records the wishes of service users on arrangements to be made in the event of their death. The registered person must ensure that the broken tiles in the kitchen are replaced. The registered person must ensure that all bathrooms and toilets in the home are fitted with a lock with a working emergency override device fitted. The registered person must ensure that the home has an out of hours emergency on-call procedure in place. The registered person must ensure that there is a system in place for seeking the views of service users on the running of the home to help inform future planning. The registered person must ensure that the home has an appropriate gas safety check carried out at least once every twelve months, by a suitably qualified person. The registered person must ensure that the home implements any requirements made by the Local Authorities Environmental Health Department. 31/08/07 31/08/07 31/07/07 31/08/07 31/08/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000007217.V339257.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000007217.V339257.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. 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