Inspection on 14/06/06 for Rosemead Care Home

This inspection was carried out on 14th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosemead Care Home 28/04/10

Rosemead Care Home 10/08/09

Rosemead Care Home 10/05/07

Rosemead Care Home 07/11/06

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 14th June 2006 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 Wynthorpe Rest Home, DS0000007217.V298123.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. Wynthorpe Rest Home, DS0000007217.V298123.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 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 Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 2002 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. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 14/6/06 and was unannounced. The inspector had the opportunity of speaking with service users, their relatives and staff from the home. The home’s acting manager was present throughout the inspection, and the proprietor was also present for part of the inspection. Overall, the inspector believes that much work still needs to be done before the home is in line with National Minimum Standards, this is reflected by the relatively high number of requirements set in this report. What the service does well: What has improved since the last inspection? 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. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 6 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 Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A Service User Guide and Statement of Purpose are provided, although the Statement must be updated. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement is in plain English and includes details of the homes organisational structure and physical environment. However, as at the last inspection it still does not accurately reflect the homes categories of registration, for example it states that the home is registered to admit service users over the age of 60, when it is in fact registered for people over 65. Further, it is not dated, and it is a repeat requirement that the Statement of Purpose is dated and in line with National Minimum Standards (NMS) and the Care Homes Regulations 2001. The Service User Guide is in line with NMS, and all service users are given a copy. Although there have been no new admissions to the home since the last inspection, the home has an admissions procedure. This states that pre Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 8 admission assessments will be carried out, and that prospective service users will be given the opportunity of visiting the home prior to making a decision as to move in or not. Service users will initially move in on a trial basis, after which a placement review meeting will be held. The home does not provide intermediate care. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 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 more must be done to ensure that service users health needs are met, for example medications must be appropriately recorded and administered, and service users must have access to all relevant health professionals. EVIDENCE: Care plans are in place for all service users. These are generally clear and comprehensive, covering needs associated with health, mobility and social and leisure needs. Plans have been drawn up with the involvement of the service user, their keyworker, the homes manager and their family were appropriate. However, there was no evidence that plans are subject to regular review, and it is required that they are reviewed at least annually. Risk assessments are also in place for all service users. As with the care plans these are of a generally satisfactory standard, although once again there was no evidence that they are subject to review. This must be addressed. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 10 At the previous inspection a requirement was made that all service users who are placed by a Local Authority have an annual review meeting in conjunction with the Local Authority. This is still not happening, for example one service user moved into the home in 1999, and there was no evidence of any Local Authority review meeting since then. All service users are registered with a GP. Records are maintained of medical appointments, but these are far from comprehensive, for instance, they merely state who the appointment is with, but do not give details of the reason for the appointment, or of any follow up action required. This must be addressed. Records indicated that service users had access to various health professionals including opticians and psychiatrists, however, as at the last inspection there was no evidence that service users have access to dental care. It is a repeat requirement that all service users have access to health care as appropriate, including dental care. On the day of inspection a chiropodist was visiting the home, and they treated service users in the homes sitting room, where other service users were sitting. It is a requirement that service users are able to see visiting health professionals in private. The home has a comprehensive medication policy, and all staff undertake training before they administer medications. No service users currently self medicate, or are on any controlled drugs. Medications are stored in a locked cabinet. Records are maintained of medications entering the home, but not of those that are returned to the pharmacist, and this must be addressed. Medication Administration Record (MAR) charts are maintained. However, these contained several unexplained gaps, and there were no guidelines in place for medications prescribed on a PRN basis. Staff were observed to treat service users with dignity and respect, for example knocking and waiting before entering bedrooms. Systems are in place to ensure that service users only wear their own clothes, and all were appropriately dressed on the day of inspection. Service users are able to use a phone in private, and are given their own mail to open. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The inspector was not satisfied that the home is meeting the needs of service users in relation to their social and leisure needs, and this must be addressed as matter of priority. EVIDENCE: The home’s Statement of Purpose states that the home will promote arts and crafts, invite professional entertainers to the home and support service users to go on day trips. There was no evidence that any of this takes place, and indeed the homes acting manager informed the inspector that at present there is very little provision of social and leisure activity in the home. It is required that service users are given the opportunity of participating in social and leisure activities both in house and in the community, in line with their assessed needs and stated preference. Service users are able to receive visitors at any reasonable time, and in private if they so wish. Relatives spoken to during the inspection informed the inspector that they are made welcome whenever they visit the home. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 12 Records are kept of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users informed the inspector that they are involved in planning menus, and get a degree of choice over meals. The kitchen was clean and tidy, and food was stored appropriately. The home has purchased a new fridge since the previous inspection. The home checks and records the temperatures for the fridge and one of the freezers on a daily basis, however, there is a second freezer used for food storage which is not checked, and this must be addressed. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 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 lack of training and inadequate polices around adult protection puts service users at an unnecessary risk and this must be addressed. EVIDENCE: The home has a complaints procedure, this includes timescales for responding to any complaints received and contact details of the CSCI. The procedure was on display within the home. Service users and relatives spoken to demonstrated a good understanding of whom they could complain to if they so wished. However, as at the previous inspection, there was no evidence that the home has a complaints log, and this must be addressed. The home has an adult protection procedure. However, this was not in line with current legislation, for example it does not make clear who has responsibility for carrying out any investigations into allegations of abuse. Further, the home does not have a copy of the Local Authorities adult protection procedures, and must obtain one. As yet, no staff in the home have received any training in adult protection issues. The proprietor informed the inspector that this would be arranged, and this is required for all staff who work at the home, including domestic and managerial staff. The inspector was satisfied that service users legal rights are protected, for example all service users are on the electoral register, and service users spoken to informed the inspector that they are able to vote in elections. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 14 Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained, and service users are provided with adequate communal and private space. EVIDENCE: 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 homes converted into one, over two floors, with a stair lift between the two floors. At the previous inspection there were several instances around the home of decorations that were in a poor state, for instance peeling wallpaper and there was a hole in the wall of the upstairs landing. All of this has been addressed. Further, at the last inspection it was noted that much of the furniture was coming towards the end of its useful life, and the inspector was pleased to note that much of this has been replaced. The home has two sitting rooms, a dining room, a conservatory and a garden. Discarded wheelchairs have been removed from the garden, Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 16 however, the garden was overgrown and unkempt, and not suitable for service users use. This must be addressed. The home has two bathroom/toilets and two toilets on their own, and two bedrooms are ensuite. Baths have been adapted, and are accessible to service users. On the day of inspection bathrooms were clean, tidy and free from offensive odour. The downstairs toilet did not have a working lock fitted, which must be addressed. All service users have their own bedrooms, these meet National Minimum Standards on size requirements, and have hand basins fitted. Bedrooms have been decorated to service users personal tastes, for example with family photographs, and contained adequate furniture, including table, chairs, wardrobes and chest of draws. Bedrooms have adequate natural light and ventilation. Heating and lighting was domestic in character, and heating in bedrooms was appropriately boxed in. The home has a designated laundry room, and washing facilities are suitable to meet service users needs. Hand washing facilities are situated throughout the home. Staff are provided with protective clothing such as gloves and aprons and the home has policies in place on infection control. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home is staffed in sufficient numbers, the home must ensure that staff receive appropriate training, and that staff recruitment is carried out in line with the Care Home Regulations 2001 and NMS. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. The home had a staffing rota on display, this accurately reflected the actual staffing situation on the day of inspection. The early shift between 7am and 3pm has two care staff on duty plus a cook, while the late shift between 3pm and 10pm has two care staff on duty. The acting manager works across the two shifts, and informed the inspector that they will help out with care duties as required. Although the home is registered for fourteen service users, there are currently only eight people living there. Further, none of the eight require two to one support with their personal care, and consequently the inspector was satisfied that staffing levels are adequate to meet service users needs. However, if there are any further admissions to the home, staffing levels will need to be reviewed. The home has policies in place on equal opportunities and recruitment and selection. However, there was evidence of poor practice with regard to the recruitment of staff to the home. Both the acting manager and the most recent care assistant to be recruited informed the inspector that they were Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 18 interviewed by just one person, it is recommended that all recruitment interviews should be carried out by at least two persons to ensure good practice with regard to equal opportunities. The care assistant started working in the home approximately six weeks prior to the inspection. They informed the inspector that they were interviewed on a Saturday, and told to start work on the following Monday two days later. At that point the home had not asked to see any proof of ID, had not taken up any employment references and had not applied for a CRB check. Other staff files checked also evidenced that the home had not got all necessary documentation in place for all staff, including CRB checks. Continued failure to abide by NMS and the Care Homes Regulations 2001 with regard to the recruitment of staff may lead the CSCI to take enforcement action against the home. The home has a policy in place on training. This states that all staff will undertake a structured induction programme on commencing work at the home. However, the inspector spoke with a care assistant who joined the home six weeks ago, they informed the inspector that as yet they have not received any structured induction training. Further, as at the last inspection, staff have still not undertaken training in all necessary statutory health and safety training, including fire safety and fist aid. In addition, staff have not received any training on working with older people, again this is a repeat requirement. Of the ten care staff employed at the home the inspector was informed that three have achieved a relevant care qualification, and that a further four staff are due to commence such a qualification later this year. It is required that at least 50 of care staff have a relevant care qualification. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36, 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 is currently without a registered manager, and this must be addressed. Further, record keeping needs to be improved, and the home must ensure that monthly Regulation 26 visits are carried out. EVIDENCE: Since the previous inspection the registered manager has left he home. An acting manager has been appointed, and at the time of inspection they had been in post for one week. The proprietor informed the inspector that it was his intention to submit an application to the CSCI to register this manager, subject to them satisfactorily completing a three month probationary period, and it is required that the home appoints a permanent manager who is registered with the CSCI. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 20 The inspector was disappointed to note that there has only been one Regulation 26 visit in the past two years. The proprietor informed the inspector during the course of the inspection that he would ensure that they are carried out. Requirements have been set around this at previous inspections, and the CSCI will be taking enforcement action to ensure that the home fully complies with NMS and the Care Home Regulations 2001 with regard to Regulation 26. It is further required that the home introduces a system of quality assurance, which includes seeking the views of service users, to help inform future planning. Not all records in the home are kept up to date, for instance care plans and risk assessments have not been regularly reviewed. Further, confidential records are not stored securely, all of this must be addressed. Records are maintained of staff supervisions. Staff have access to their supervision records, and records evidenced discussions on staffing and service user issues. However, several staff have not received any formal supervision at all during 2006, and it is required that all staff receive regular formal supervision, at least six times a year. Fire fighting equipment was situated around the home, and last serviced in July 2005. Fire exits were free from obstruction on the day of inspection. Alarms are supposed to be checked weekly, but had not been checked since the 19/5/06, and this must be addressed. COSHH products were stored securely, and the home had in date employer’s liability insurance cover. There was evidence of in date safety checks on PAT testing, gas and electrical installation. The home could not evidence that it checks hot water temperatures, and it is required that all hot water outlets used for personal care are checked at least weekly to ensure that they are 43 degrees centigrade. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 21 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 1 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 2 2 2 Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 13 Requirement Timescale for action 30/09/06 2. OP18 13 3. OP29 19 4. OP38 138 The registered person must ensure that all service users have access to appropriate health care, including regular access to dental care, and that records are maintained of all appointments. (Timescale 31/12/05 not met) The registered person must 30/09/06 ensure that all staff who work in the home are aware of their responsibilities with regard to adult protection issues, and are familiar with any relevant policies and procedures, and that they receive appropriate training in adult protection issues. (Timescale 31/12/05 not met) The registered person must 30/09/06 ensure that all documentation required by Schedule 2 of the Care Homes Regulations 2001 is in place for all staff working in the home. (Timescale 31/12/05 not met) The registered person must 30/09/06 ensure that the home tests and records on a weekly basis all hot water temperatures used for DS0000007217.V298123.R01.S.doc Version 5.2 Wynthorpe Rest Home, Page 23 5. OP7 13 6. OP9 13 7. OP9 13 8. OP9 13 9. OP12 16 10. OP30 13 11. OP36 18 personal care to ensure they do not exceed 43 degrees Celsius. (Timescale 31/12/05 not met) 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 31/12/05 not met) The registered person must ensure that records are maintained of all medications that are returned to the pharmacist. (Timescale 31/12/05 not met) The registered person must ensure that MAR charts are accurately maintained, and that all medications administered are accounted for. (Timescale 31/12/05 not met) The registered person must ensure that written guidelines are in place for the administration of all medications prescribed on an as required basis. (Timescale 31/12/05 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. (Timescale 31/12/05 not met) The registered person must ensure that all staff receive statutory health and safety training in moving and handling, first aid and food hygiene. (Timescale 31/12/05 not met) The registered person must ensure that staff receive regular formal supervision, at least six DS0000007217.V298123.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 Wynthorpe Rest Home, Version 5.2 Page 24 12. OP1 4 and 6 13 OP7 15 14. OP8 13 15. OP8 13 16. OP15 13 17. OP16 22 18. OP18 13 19. OP18 13 20. OP19 23 times a year. (Timescale 31/12/05 not met) The registered person must ensure that the homes Statement of Purpose is in line with National Minimum Standards and the Care Homes Regulations 2001, and that it is dated and subject to regular review. The registered person must ensure that all care plans are subject to regular review, at least once a month. The registered person must ensure that comprehensive records are maintained of all service users medical appointments, including details of any follow up action required. The registered person must ensure that service users are able to see visiting health professionals in private. The registered person must ensure that the temperatures of all fridges and freezers in the home used for food storage are checked and recorded at least daily. The registered person must ensure that the home has a complaints log, which clearly records any complaints received, including details of any investigations, outcomes and actions taken. The registered person must ensure that the home has a current version of the host Local Authorities adult protection procedures. 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. The registered person must DS0000007217.V298123.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 Page 25 Wynthorpe Rest Home, Version 5.2 21. OP21 23 22. OP28 18 23. OP30 18 24. OP30 18 25. OP31 8 26. OP33 24 27. OP37 17 28. OP38 13 and 23 29 OP7 15 ensure that the homes grounds and gardens are well maintained. The registered person must ensure that all toilets and bathrooms in the home are fitted with a working lock, that have an emergency override device. The registered person must ensure that at least 50 of the care staff employed at the home have obtained a relevant care qualification. 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. The registered person must ensure that all care staff who work in the home undertake appropriate training on working with older persons. The registered person must appoint a permanent manager to the home, and apply for their registration with the CSCI. The registered person must introduce quality assurance systems into the home, which seek the views of service users, to help inform future planning. The registered person must ensure that the home maintains all necessary records, policies and procedures, as required by the National Minimum Standards and the Care Homes Regulations 2001. The registered person must ensure that the homes fire alarms are tested at least once a week. The registered person must ensure that all service users placed by a Local Authority, have a review meeting at least DS0000007217.V298123.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 Wynthorpe Rest Home, Version 5.2 Page 26 annually in conjunction with that Local Authority. 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 OP29 Good Practice Recommendations It is recommended that all recruitment interviews are carried out by at least two persons, in line with good practice as regards equal opportunities. Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wynthorpe Rest Home, DS0000007217.V298123.R01.S.doc Version 5.2 Page 28 - 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. 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