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Inspection on 16/04/07 for Ross Wyld Nursing Home

Also see our care home review for Ross Wyld Nursing Home for more information

This inspection was carried out on 16th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Food was of a satisfactory standard, and people informed the inspector that it was served in reasonable quantities. The home has made arrangements to provide a variety of social and leisure activities, and appropriate complaints and adult protection procedures are in place.

What has improved since the last inspection?

There have been some improvements since the previous inspection, and the overall number of requirements set has fallen slightly. The inspector was pleased to note that the home has devised a system whereby people now receive any income generated by their individual savings, and the administration and recording of medications has improved.

What the care home could do better:

As stated, there is still much that needs to be done. Care plans and pre admission assessments must be comprehensive, the environment still needs attention, and record keeping is of a generally poor standard. The home must ensure that staff are appropriately supervised, and have access to all relevant training, including on adult protection and health and safety issues.

CARE HOMES FOR OLDER PEOPLE Ross Wyld Nursing Home Ross Wyld 458 Forest Road Walthamstow London E17 4PZ Lead Inspector Rob Cole Unannounced Inspection 16th April 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 Ross Wyld Nursing Home DS0000025960.V336433.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. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ross Wyld Nursing Home Address Ross Wyld 458 Forest Road Walthamstow London E17 4PZ 0208 521 8773 0208 520 0690 ross.wld@fsch.co.uk 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) Tamaris (South East) Limited (a wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Lutchemee Hele Care Home 54 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (25), of places Physical disability (7) Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow the home to provide continuous care for two named service users and to permit admission of one named service user with mental health needs. 4th September 2006 Date of last inspection Brief Description of the Service: Ross Wyld is a care home registered to provide care for a maximum of 54 service users. This includes 25 places for those requiring nursing care, 22 places for older people with dementia and 7 places for younger adults with physical disabilities. The registered provider is Tamaris Ltd, part of the Four Seasons Health Care Group. The home is a large purpose built, three storey detached house with 48 single bedrooms and three double bedrooms located across all three floors. All floors are accessible via a lift. The home is situated on Forest Road, in the London Borough of Waltham Forest. The home is close to shops, transport networks and other local amenities. Ross Wyld Nursing Home DS0000025960.V336433.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 16/4/07 and was unannounced. The inspector had the opportunity of speaking with people who use the service, staff, and the homes manager was present throughout the inspection. The inspection also included an examination of records and documents, and a tour of the premises. Throughout this report the term “people” has been used to describe those people who live at the home. Other persons referred to are referred to by specific names, for example staff or health professionals. Overall, the inspector was disappointed to note that there has been only very limited improvement to the home since the last inspection, and a total of twenty seven requirements have been made, eighteen of which are repeat requirements. Continued failure by the home to comply with the National Minimum Standards (NMS) and the Care Homes Regulations 2001 may lead the CSCI to take enforcement action against the home. What the service does well: What has improved since the last inspection? What they could do better: As stated, there is still much that needs to be done. Care plans and pre admission assessments must be comprehensive, the environment still needs attention, and record keeping is of a generally poor standard. The home must ensure that staff are appropriately supervised, and have access to all relevant training, including on adult protection and health and safety issues. Ross Wyld Nursing Home DS0000025960.V336433.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. Ross Wyld Nursing Home DS0000025960.V336433.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 Ross Wyld Nursing Home DS0000025960.V336433.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): 1,2,3,4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although people are given the opportunity of visiting the home before making a decision to move in or not, the home must do more to determine whether or not it can meet their individual needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English. The Statement of Purpose includes details of the aims and objectives and of the organisational structure of the home. However, as at the last inspection, it has still not been dated or reviewed, for example it states that the post of care manager within the home is vacant, but the inspector was informed that this post has been filled for the past three years. The Service User Guide has been reviewed since the last Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 9 inspection. It contained a summary of the Statement of Purpose, and a copy of the homes complaints procedure, and was in line with National Minimum Standards. All people have been provided with a written contract/statement of terms and conditions. They have been signed by a representative of the home, and the person who uses the service, or family member where appropriate. They include details of fees payable, and services provided. There have been four new admissions to the home since the previous inspection. Pre admission assessments were carried out for all of these people by either the homes manager or deputy manager. For three of these assessments, the inspector was pleased to note that their quality had improved since the previous inspection. However, for the other assessment, as at the last inspection, the level of information and detail provided was extremely limited. The home uses a pro forma to carry out assessments. These include a section on each area of need, to indicate the level of support required, and to record the persons usual routine and personal preference when meeting these needs. These sections had been left completely blank for one service user, and there was no detailed information at all about what there needs were, or how they were to be met. It is a repeat requirement that comprehensive pre admission assessments are carried out for all prospective service users, to determine how the home can meet the needs of people moving into the home. Through discussion with people there was evidence that people are given the opportunity of visiting the home before making a decision as to move in or not. The home does not provide intermediate care. Ross Wyld Nursing Home DS0000025960.V336433.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 poor. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home should be doing more to ensure peoples health needs are met, for example ensuring that people have appropriate access to relevant health care professionals. EVIDENCE: Care plans are in place for all people. These are drawn up my senior members of staff, with the involvement of people using the service. Care plans covered needs around nursing care, personal care, mobility and dementia. However, those care plans checked by the inspector did not include information on how the home was to meet peoples needs around social interests, religion and cultural needs. Care plans must be comprehensive, covering all areas of need, and indicating how the home was able to meet these needs. Care plans are reviewed on a monthly basis. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 11 Risk assessments were in place for all people. Those seen by the inspector were of a satisfactory standard, covering risks associated with mobility, falls and epilepsy. They identified risks, and included strategies to manage and reduce risks, and were subject to regular review. All people are registered with a GP. Records are maintained of medical appointments, including details of any follow up action. However, these records indicated that people do not have access to all relevant health care professionals as appropriate. For example, several people have not had any access to dental care in the past two years, and this must be addressed. Used continence products within the home are disposed of appropriately. The home has a medication policy in place. All medications on the nursing unit are administered by qualified nurses. On the dementia unit all medications are administered by staff who have undertaken training in medication. The medication policy for the home states that there must be a returns book for recording any medications no longer required. Such a book was in place on the dementia unit, and this was appropriately maintained. However, the inspector was informed that the nursing unit no longer maintained records of any medications that are disposed of, and it is required that the home keeps clear records of medications disposed of, including the name of the medication, who it belonged to and the quantity. It was further noted that as at the last inspection, the home does not have guidelines in place on the administration of individual medications prescribed on an as required basis. For instance, one person has been prescribed LORAZEPAM tablets on an as required basis, but there were no guidelines in place around when it should be administered, and a repeat requirement has been made around this issue. However, the inspector was pleased to note that since the previous inspection Medication Administration Record charts are now maintained appropriately, and these indicated that medications are now appropriately administered. Medications are stored securely, and the home keeps records of medications entering the home. The manager informed the inspector that people could remain in the home with a terminal illness, as long as the home could meet their medical needs. However, the home has not sought the views of all people on their wishes around arrangements to be made in the event of their death, and this must be addressed. People spoken to informed the inspector that staff treat them with dignity and respect. Through observation there was evidence that staff respect peoples privacy, for example people are given their own mail to open, and staff were seen to knock and wait for an answer before entering bedrooms. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. The inspector was satisfied that service users have control over their daily lives, and that they are able to access the community. EVIDENCE: The home has a designated full time activities coordinator, and activities room. An activities programme was on display within the home, and included quizzes and bingo. People spoken to informed the inspector that they enjoyed participating in the activities programme. The inspector was informed that people have the opportunity of visiting the local community, including shops, parks and cafes. The home arranges occasional day trips, for example to Bognor Regis, and a BBQ is planned to take place in May. One person regularly goes to a local church, while another goes to a temple. A priest visits the home once a month. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 13 Through observation and discussion there was evidence that people have control over their daily lives, for example they are able to get up as they choose, and were observed to move freely around communal areas. The home has a visitors policy in place. Visitors are welcome at any reasonable time, and can see people in private if they so wish. Records are maintained of menus, people spoken to informed the inspector that they found the quality of food to be good, and served in sufficient quantities. Those people who are able to, were observed to help themselves to drinks throughout the day, while staff were seen to offer drinks to other people at regular intervals. Fresh fruit was available, and all staff involved in food preparation have undertaken training in food hygiene. Records are maintained of fridge and freezer temperatures, and food was stored appropriately. The kitchen was clean and tidy, however, there were several broken tiles on the walls in the kitchen, and a requirement has been made that these must be replaced. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home has appropriate procedures in place around complaints and protection, it is the inspectors view that the risk of abuse would be further reduced by all staff undertaking appropriate training. EVIDENCE: The home has a complaints procedure in place. This includes timescales for responding to any complaints, and contact details of the CSCI. A copy of the procedure was on display within the home. The home also has a complaints log, this evidenced that complaints received have been appropriately recorded and investigated. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. This appeared to be in line with current legislation. The manager informed the inspector that it was intended that all staff employed at the home would receive training in adult protection issues. However, at the time of the inspection there were several staff who had not yet undertaken such training, and staff spoken to demonstrated only a limited understanding of their roles and responsibilities with regard to adult protection Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 15 issues. It is therefore a repeat requirement that all staff employed at the home receive adult protection training as appropriate. The inspector was satisfied that peoples legal rights are protected, for example all people are on the electoral register, and have the opportunity of voting in elections. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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 adequate. This judgement has been made using available evidence including a visit to this service. The homes environment is in need of some decorating work, and furniture in bedrooms was often in a poor state. EVIDENCE: The home is situated in the Walthamstow area of the London Borough of Waltham Forest, and is close to shops, transport networks and other local amenities. Whilst it was positively noted that some redecorating work has been carried out, there is still some to do. Throughout the home there are instances of peeling and faded wallpaper and cracked paint. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 17 Communal areas consist of sitting rooms, dining rooms and two designated smoking rooms, and are sufficient in numbers to meet service users needs. Likewise the inspector was satisfied that the home has sufficient numbers of bathing and toilet facilities to meet service users needs. However, the locks on the first floor shower room and bathroom did not have an emergency override device fitted, and this must be addressed, and is a repeat requirement. The homes garden was generally well maintained, although there were several items of discarded furniture in the garden, including a bath and a bed, which must be removed. Bedrooms were also found to be in a generally poor state. Many contained broken items of furniture, and dirty or stained carpets. Furniture in bedrooms was often found to be in a poor state, and several bedrooms had a strong offensive odour. This must be addressed. Bedrooms met NMS on size requirements, and had adequate natural light and ventilation. Several bedrooms did not have any locks fitted to the doors. It is required that all bedrooms have working locks fitted, and that people are offered keys to their rooms subject to satisfactory risk assessment. There was no evidence of any assessment of the premises by a suitably qualified person having taken place and no evidence of aids and adaptations being provided, despite this being identified in previous inspection reports. It is a requirement that such an assessment is undertaken and that the registered person provides any necessary aids, adaptations and equipment to meet the needs of service users. This is a repeat requirement. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector believes that the home is staffed in sufficient numbers, but it is required that service users receive appropriate support from staff on duty. EVIDENCE: The home provides 24-hour support including an emergency on-call procedure and waking night staff. There was a staffing rota, this accurately reflected the staffing situation on the day of inspection, and since the previous inspection now indicates who is in charge of the home at any given time. Although the inspector was satisfied that the home is staffed in sufficient numbers to meet peoples needs, they had concerns that staff are not always deployed within the home appropriately, and therefore that service users are not always supported as appropriate. For example, when the inspector arrived at the home, they sat in the main downstairs lounge with fifteen people. It was approximately ten minutes before any staff entered the room. This was one member of staff, and they did not interact in any way with the people in the room. Instead, they sat in a quiet corner and started to read a daily Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 19 newspaper. This was despite the fact that the risk assessments indicated that several people in the room were at risk of falls, and that they should be closely monitored. The inspector brought these issues to the attention of the homes manager, and it was noted that for the remainder of the inspection, people in this room were supported appropriately. The home had policies in place on recruitment and selection and equal opportunities. The inspector checked several staff employment files at random, these contained all required documentation, including CRB checks and proof of ID. The inspector was informed that over 50 of the care staff employed at the home have a relevant care or nursing qualification. All staff undertake a structured induction programme. Staff have recently had training in dementia and food hygiene. However, as at the last inspection, not all staff have had necessary health and safety training, such as moving and handling and fire safety. It is a repeat requirement that all staff undertake all necessary statutory health and safety training as appropriate. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The inspector believes that much more must be done by the homes management before the home is fully compliant with NMS and the Care Homes Regulations 2001. Staff must be appropriately supervised, and the home must ensure that it has adequate quality assurance systems in place. EVIDENCE: The homes manager is a registered nurse, with several years experience of working in residential care homes. Staff and people who use the service Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 21 spoken to informed the inspector that they found the manager to be approachable and accessible. However, the inspector was disappointed to note that eighteen of the requirements made in this report are repeat requirements, and it is required that the manager takes prompt and appropriate action to comply with any requirements made, within the timescales given. It is further required that the home introduces a comprehensive system of quality assurance, which includes seeking the views of people who use the service, to help ensure that their needs are been appropriately met, and to inform future planning. The home could only evidence that there had been six Regulation 26 visits in the past twelve months. It is required that these visits are carried out on a monthly basis, and that a copy of the reports of these visits is retained in the home, and a copy is forwarded to the CSCI. Record keeping within the home was generally of a poor standard. Many records, for example care plans and medication records, have not been kept up to date. Records were however stored securely, and staff and people who use the service can access their records as appropriate. Although staff receive formal one to one supervision, it is not always as regular as required by the NMS, for example the homes deputy manager has had only one formal supervision in the past twelve months. It was further noted that only some, but not all, staff have an annual appraisal. It is required that all staff receive regular formal one to one supervision at least six times a year, and that all staff have an annual appraisal of their performance, which is subject to regular review. The home holds money on behalf of people in a locked safe. Records are maintained of financial transactions, those checked by the inspector were satisfactory. The home has a pooled bank account in which several people have their savings. However, the inspector was pleased to note that since the previous inspection a system has been put into practice whereby people receive any income generated by their own savings. Fire extinguishers were situated around the home, these were last serviced in November 2006. Fire alarms were last serviced on the 27/3/07, and are tested weekly by the home. There was evidence that the home holds regular fire drills. Hot water and fridge/freezer temperatures are routinely checked, and COSHH products were stored securely. The home had in date safety certificates for gas safety and PAT testing. However, the home could not evidence that it has had a periodic electrical installation safety check within the past five years, and this must be addressed. Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 2 3 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 2 2 2 2 2 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X 3 1 2 2 Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 OP22 Regulation 23 Requirement Timescale for action 31/07/07 2. OP7 14 3. OP10 12 The registered person must demonstrate that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist with specialist knowledge of the client group catered for; and provide evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. (Timescale 30/11/06 not met) The registered person must 31/07/07 ensure that all care plans demonstrate how each of the assessed needs of the service users are met, and that care plans are subject to regular review, at least monthly. (Timescale 30/11/06 not met) The registered person must 31/07/07 ensure that all service users bedrooms are fitted with suitable locks, and service users provided with a key unless a completed risk assessment indicates otherwise. This must be recorded DS0000025960.V336433.R01.S.doc Version 5.2 Ross Wyld Nursing Home Page 24 4. OP18 18 5. OP19 23 6. OP19 23 7. OP9 13 8. OP24 16 9. OP36 18 10. OP21 12 11. OP1 6 in the individual plan of care detailing the reasons why. (Timescale 30/11/06 not met) The registered person must ensure that all staff working in the home receive training in adult protection issues and the protection of vulnerable adults. (Timescale 30/11/06 not met) The registered person must ensure that all parts of the care home are kept in a good state of repair and reasonably decorated. (Timescale 30/11/06 not met) The registered person must ensure that all incidents of peeling wallpaper are redecorated. (Timescale 30/11/06 not met) The registered person must ensure there are clear guidelines in place for the administration of all medications prescribed on a PRN basis. (Timescale 30/09/06 not met) The registered person must ensure that all bedrooms contain adequate furniture, and that this furniture is in a good state of repair. (Timescale 30/11/06 not met) The Registered person must ensure that all staff receive formal supervision at least six times a year and that a written record is maintained which details the nature of the discussion and topics discussed. (Timescale 30/11/06 not met) The registered person must ensure that all bathrooms and toilets have suitable locks fitted with an override device for staff to use in an emergency. (Timescale 30/11/06 not met) The registered person must ensure that the homes Statement of Purpose is dated DS0000025960.V336433.R01.S.doc 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 Ross Wyld Nursing Home Version 5.2 Page 25 12. OP27 18 13. OP20 23 14. OP30 13 and 18 15. OP3 14 16. OP4 14 17. OP37 17 18. OP38 13 and 23 19. OP8 12 and subject to regular review. (Timescale 30/11/06 not met) The registered person must ensure that all service users are provided with appropriate and adequate levels of care from nursing and care staff at all times. (Timescale 30/09/06 not met) The registered person must ensure that all items of discarded furniture are removed from the homes grounds. (Timescale 30/11/06 not met) The registered person must ensure that staff undertake all required statutory health and safety training as appropriate. (Timescale 30/11/06 not met) The registered person must ensure that comprehensive pre admission assessments are carried out on all prospective service users before they move in to the home, covering all areas of potential need. (Timescale 30/09/06 not met) The registered person must be able to demonstrate the homes capacity to meet the assessed needs of service users at all times. (Timescale 30/09/06 not met) The registered person must ensure that the home maintains all records accurately and up to date in line with the National Minimum Standards and the Care Homes Regulations 2001. (Timescale 30/11/06 not met) The registered person must ensure that the home has an appropriate electrical installation safety check carried out at least once every five years. (Timescale 31/10/06 not met) The registered person must ensure that service users have DS0000025960.V336433.R01.S.doc 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 31/08/07 Page 26 Ross Wyld Nursing Home Version 5.2 20. OP9 13 21. OP11 15 22. 23. 24. OP15 OP24 OP31 23 23 9 25. OP33 24 routine access to all relevant health professionals as appropriate, including dental care. The registered person must ensure that the home maintains a record of all medications that are disposed of. The registered person must seek and record the views of service users (or their next of kin where appropriate) on their wishes in the event of their death. The registered person must ensure that all broken tiles in the kitchen are replaced. The registered person must ensure that all bedrooms are free from offensive odours. The registered person must ensure that the home takes steps to ensure all requirements made in this report are completed with in the timescales given. The registered person must implement a system of quality assurance, which includes seeking the views of people who use the service, to help inform future planning. The registered person must ensure that unannounced Regulation 26 visits are carried out monthly, and that a copy of the report of these visits is maintained in the home, and a copy forwarded to the CSCI. The registered person must ensure that all staff undertake an annual appraisal of their performance, which is subject to regular review. 31/05/07 31/08/07 31/08/07 31/08/07 31/08/07 31/08/07 26. OP33 23 31/05/07 27. OP37 18 31/08/07 Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 27 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 Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 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 Ross Wyld Nursing Home DS0000025960.V336433.R01.S.doc Version 5.2 Page 29 - 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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