Inspection on 06/03/06 for Rushes House

This inspection was carried out on 6th March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rushes House 08/08/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rushes House 2 St Martins Road Marple Stockport Cheshire SK6 7BY Lead Inspector Sylvia Brown Announced Inspection 6th March 2006 08:00 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 Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rushes House Address 2 St Martins Road Marple Stockport Cheshire SK6 7BY 0161 427 7332 0161 456 9985 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) Mrs Mary B Rushe Mrs Mary B Rushe Care Home 17 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (17) Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 17 services users to include: *up to 17 service users in the category of OP (Old age not falling within any other category). *up to 14 service users in the category of DE(E) (Dementia over 65 years of age). *up to 10 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). As from the date of registration, there must be no further admissions of Younger Adults (persons under 65 years of age). Five named service users out of category by reason of age. This is the first inspection under the new ownership. 2. 3. Date of last inspection Brief Description of the Service: The registered owner, Mrs Rushe, was registered by the CSCI as a fit person to run a care home in 2005. Mrs Rushe is also registered as the manager and is in daily attendance at the home. Rushes House is not a spacious home and is currently undergoing major refurbishment in all areas. Its unusual layout and internal shapes place restrictions on how far the home can be altered, however substantial work is underway to create dining space and provide improved disabled bathing/ showering facilities on the ground floor. The home is registered to accommodate older service users. However, there are a number of younger adults who have mental health difficulties residing at the home. Those residents may remain at the home as long as they desire and as is suitable. Vacancies arising can no longer be offered to people under the age of 65 years. Accommodation is on four floors with a lift serving each area. The home offers both single and double bedroom accommodation. There is currently one lounge which is used by residents who smoke, there is a dining room which offers two additional lounge chairs for non smoking residents. This issue is currently under review and the home is actively encouraging a reduction in smoking. The home is in a pleasant area in the village of Marple. It is close to local shops, parkland and canals. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of Rushes House, it was announced and completed over three visits, with a total of 15 hours spent on the premises. The inspector spent time with the registered provider, who is also the registered manager, discussing the many changes currently being made at the home. Residents’ files were looked at, as were health and safety records. All parts of the building were inspected and the inspector spent time with residents in their rooms. Staff were observed as they completed their duties and two meal times were shared with the residents. Staff on duty met with the inspector who asked their opinions on the change of management and routines within the home. Prior to the inspection the home was provided with a pre-inspection questionnaire which was completed and returned before the inspection commenced. Comment cards were provided to residents, relatives and professional visitors. At the time of writing the report nine resident and two relative comment cards were returned. A confidential care worker survey was also completed. All levels of staff were provided with the opportunity to comment on the service provision and changes made under the new management structure. At the time of writing five survey forms had been returned. The inspection report details, where relevant and applicable, comments received through the inspection process. What the service does well: The inspection identified that residents at Rushes House feel satisfied with the service provision. At the time of the inspection many aspects of the home were under development and though not fully completed, there were clear indicators that positive changes were and had been made. The home was managing to integrate the needs of the younger adults, who have mental health difficulties, and the needs of the older people in a more appropriate manner. The younger adults appeared more relaxed and happy with increased interaction between each other observed. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Though revised, the home’s statement of purpose requires information to ensure residents have up to date information. additional Medication administration records were not maintained to the required standard. Fire safety procedures were not followed correctly, increasing the risk of harm to residents, in that, some doors were wedged open and staff required practical fire drill training. Staff levels require review to ensure numbers are sufficient to meet the needs of residents at all times. Robust recruitment and selection procedures need to be followed at all times to safeguard residents. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 7 Residents’ accounts need auditing to ensure balances are correct. 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. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 8 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 Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 9 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, 4 & 5 Satisfactory information is provided to prospective residents to enable them to make decisions. Needs are assessed and contracts of residency supplied. EVIDENCE: The home has developed a new statement of purpose and service user guide, which are to be provided to current and prospective residents. Although improved, some required information has not been included. Residents have been issued with new terms and conditions of residency, however these have not been signed as agreed by the resident or their representative. Residents are visited in their own home or current placement by the registered person and have their needs assessed. Where residents are funded, assessments are also received from the Local Authority. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 10 The home has yet to develop formal systems for informing residents and relatives that the home can meet the residents’ individual needs. Records demonstrated that residents and relatives are encouraged to visit the home to observe the accommodation and daily routines. Visits are designed to meet the individual’s need and preferences enabling them to have as many visits as they need before making any decisions. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 11 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 & 10 Residents have plans of care and have their health care needs met. Medication administration records were not maintained correctly. EVIDENCE: The inspector looked at two care plans. The registered owner has introduced new care plans for all residents. Information recorded residents’ healthcare needs and personal preferences. Assessments were in place and kept under review. Residents told the inspector that they either went to their own doctor or the doctor visited when they were unwell. All comment cards stated that they felt well cared for and that they received the support they required. Residents’ care files recorded professional visits and information about treatments received. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 12 At the time of the inspection the home’s medication process was under review. The previous system remained in place, however the registered provider stated her overall dissatisfaction with the system and was in the process of seeking advice on differing administration and recording systems. The registered provider was able to demonstrate that a new medicines trolley had been ordered which will improve the management of medication and its security. Inspection of the medication administration records identified they were incorrectly maintained. Signature omissions were evident and prescription details were not always followed. Without exception, all residents spoken with stated they felt positive about the changes in management and management style. One comment card stated “since Mrs Rushe came here, I feel things have improved enormously” whilst another stated “everybody is very nice in this home and the staff treat you very well”. Staff were observed talking and assisting residents in a respectful and dignified manner and, in general, those living in the home were observed to be relaxed and happy. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Residents live as they desire and are able to make decisions and choices about their daily routines. They received a varied diet which offers choice. EVIDENCE: The inspector observed that residents appeared to have been supported to make more decisions and choices for themselves. One resident, who remains in their room, stated that their pattern for daily routines have not changed and that though staffing changes have occurred, care support has not been reduced. Other more able residents were observed rising as they desired and receiving breakfast when they wished, some preferring breakfast in their room whilst others preferred a communal setting. When asked about activities, most residents stated they were satisfied. A number of the more able residents are supported to go to local shops each day and visit places independently within the community. Records evidenced that some residents had gained confidence to do more for themselves and were achieving more appropriate independent self-caring skills. However, one relative’s comment card stated that “I wish there was a little more stimulation and exercise provided”. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 14 The registered provider stated that she recognised the home’s activities programme requires improving, however due to the complexities of managing the building upgrade, progress to improve the social aspects of the home has not been made as she desired. One resident was observed to be making their own drinks and snacks. The upgrading programme will include improved facilities to support residents to make drinks and snacks for themselves as they wish. The inspector observed mealtimes and looked at the home’s menu. The registered provider has developed a new menu which offers more variety and choice. Residents are able to have a cooked breakfast when they wish and as many drinks as they desire. One comment card stated “the food has changed and it is better than before”. During the inspection the inspector spoke with residents about the meals served, all were satisfied, stating that, overall, they enjoyed the meals and felt able to ask for different options which may not be on the menu. The home has employed a new cook. Employment records demonstrated he was appropriately trained and qualified, however the registered provider has plans in place to ensure he receives additional training to ensure specialised diets can be prepared and that the nutritional value of food is known. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints procedure does not meet required standards. Adult protection procedures are in place, however the management team and staff require up to date training to ensure they are aware of their responsibilities to safeguard residents from abuse. Staff are not adequately trained in safeguarding procedures. EVIDENCE: The home has a complaints procedure in place. The registered provider stated that all complaints are recorded and that action taken to investigate will be detailed, as would the outcome. Systems are to be introduced to ensure that all residents and visitors receive a copy of the new complaints procedure. Evaluation of the complaints procedure identified that it needs further development to ensure that it can be easily understood. Information regarding how the process works, how long the process takes, a person’s right to refer the complaint to the ombudsman and how the complainant will be informed of the outcome were not included. Both relative comment cards stated they had had no cause for complaint, with one stating “we are delighted with the way my mother is cared for at Rushes House”. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 16 The registered provider stated that the previous home owner had stated staff were trained in adult protection procedures, however after consultation with staff she has concluded that they require further up to date training and guidance. The registered provider has yet to complete Adult Protection Alerter training. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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 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 & 26 Residents live in comfortable surroundings, which are being upgraded. EVIDENCE: As stated within the summary of the report, since becoming the owner of Rushes House the registered provider has commenced an extensive upgrading programme which has culminated in some rooms being decommissioned and others used as temporary areas until upgrading is complete. Without exception, all residents spoke positively of the changes and stated fully their agreement to having their home environment disrupted. The registered provider is aware that in order to ensure repairs and upgrading are completed in a timely manner, she is required to provide a detailed action plan which identifies all aspects of the work to be undertaken and the individual timescales for completion. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 18 There are no changes to the grounds of the home, however eventual plans are that a conservatory area will be added to the home. The inspector observed that doors to bedrooms where residents preferred to remain all day were wedged open. The home’s previous fire safety report identified a number of requirements and recommendations. The provider has consulted with the home’s fire safety officer and requested a full inspection in order to have up to date information regarding outstanding requirements and recommendations. At the time of the inspection the communal rooms used by residents were in the process of change. The dining room in the basement has been assessed by the provider as unsuitable for use. She stated that it did not offer residents a homely or pleasant setting for them to enjoy their meal. Consequently, a number of residents did not use the area. A double bedroom has been converted on the ground floor to provide residents with a more suitable dining room, though currently, this does not enable all residents to have their meals in one sitting. Additional dining space will be created when the kitchen area is moved and developed into a further dining room. The inspector observed that the new dining area had a toilet facility and that the door to the area opened directly into the dining room. Lounge areas are also compromised whilst upgrading is underway. When asked, residents stated they felt they were able to cope with the changes and be flexible about seating arrangements until the work was finished. A number of residents smoke, however they have a designated lounge. The registered owner is aware that a non smoking lounge must be made available for non smoking residents. Communal areas have been redecorated and new quality carpets have been fitted. New lighting is planned and curtaining and additional fixtures and fittings are being introduced. Bathing and showering areas require upgrading and will be included in the overall improvement plan. The registered provider stated it is her intention to provide disabled facilities, including at least one walk-in shower room. Aids and adaptations are in place to support residents. A call system is fitted throughout the home which has been serviced and certified as working correctly. The home does not currently have a loop system fitted. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 19 Work has commenced on the upgrading of bedrooms. Some have received new carpets, curtains and redecoration. All residents are to have new beds and bedding, including quilts and pillows where they are seen to be below the required standard. The registered provider has some vacant rooms which have been upgraded, these have been offered to residents, giving them first opportunity to move whilst their rooms are upgraded or change rooms permanently. New fixtures and fittings have been supplied, including wardrobes and drawers. A number of bedroom doors contain windows, the registered provider is aware that these doors must be replaced with doors that offer increased privacy as part of the upgrading programme. The registered provider has not yet addressed how or if residents have been provided with keys to their rooms. As a consequence, door locks are being reviewed to ensure they are of the appropriate safety design and that they all have keys. Once completed, residents will be offered keys to their room. The home was well lit and warm on the day of the inspection. Residents informed the inspector that the heating had failed and that the day before the inspection they had felt the cold. The registered manager confirmed the information and explained the process undertaken to have heating systems repaired in a timely manner. Residents stated they are usually kept warm and that the central heating usually heats the home appropriately. The laundry facilities were looked at. Again, upgrading has commenced and whilst walls and floor finished do not comply with Environmental Health standards, delays have occurred due to the damp proofing process. Washing machines comply with the required standard and were in sufficient numbers to meet the demands of the home. There are infection control procedures in place. Staff confirmed they had received infection control training and were observed to be following procedures in practice. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 20 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 & 30 Residents receive support from competent staff but the numbers of staff on duty are not always sufficient to meet residents’ needs. Robust recruitment procedures are not followed. EVIDENCE: On the days of the inspection staff were provided in sufficient numbers to meet the needs of residents. The duty rota identified that at weekends staffing levels were reduced. Staffing levels should be determined by the dependency of residents and the layout of the building plus other roles and responsibilities that care staff may need to fulfil. The home should be following the guidance set out by the Residential Forum in the publication Care Staffing in Care Homes For Older People. The duty roster failed to record where staff complete domestic and/or cooking duties in addition to care duties. All duties should be detailed separately to enable the home to demonstrate that it provides appropriate care support. The rota also detailed that staff are routinely rota’d to complete 14.5 hour duties. Whilst it is understandable that covering another’s duty at short notice may require additional hours and long duties being occasionally worked, it is not best practice to routinely rota staff for such long shifts. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 21 The duty rota also failed to detail the actual complete duty, in that, starting and finishing times were not accurate or always recorded. The home has yet to implement robust recruitment procedures. Inspection of three staff files identified inconsistent practice. CRB checks were used from previous employment, letters of appointment were absent and current photographs were not in place for all staff. The home continues with NVQ training. The pre-inspection questionnaire stated that three of the staff team have completed NVQ training. The registered provider stated that the ratio was higher, however a number of staff have left who had or were completing their NVQ training. The registered provider is aware that the target set for NVQ training is 50 of the staff team. Staff confirmed that they are paid for training, attending staff meetings and are able to take breaks during their working day. There have been some significant issues arising within the staff team since the registered provider took over the home culminating in staffing changes. As a consequence, the CSCI have conducted a confidential staffing survey. The information received from staff currently employed at the home indicates that terms and conditions of employment have improved and that staff are pleased with the way the home is developing and how it is managed. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 22 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, 32, 33 ,34, 35, 36 & 38 Residents live in a well managed home which is run in their best interests, comfort and safety. EVIDENCE: The registered provider is experienced and appropriately qualified to run a care home. Her forthright management style is direct and she is clear about her aims to develop the home and how it is to be run. Residents have responded well to the change in management style, one informed the inspector that they liked to “know who the boss is” saying “She sorts everything out now, its better”. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 23 The home has not yet had the opportunity to complete a quality assurance procedure. The registered provider stated that once the service has been developed and the home upgraded, it is her intention to complete a quality audit as required. The home’s insurances are up to date and correct. Health and safety records demonstrated that the safety of residents is a priority. All equipment has been serviced and considerable work undertaken to ensure safety standards, particularly relating to the lift. Small balances are held for residents and accounts maintained. After evaluation the inspector identified that some inaccuracies were evident within the accounting system prior to the new owner taking responsibility. Action has been required to ensure full auditing procedures are carried out and that residents’ accounts are correct and monies refunded if deficits are found. Staff confirmed that formal supervision has commenced, however some are outstanding. The registered owner/manager has been working alongside the staff team and completing all duties. Staff stated they receive regular practical supervision and guidance and are made aware of the new owner’s required standards. Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 2 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 3 2 2 3 3 Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 ,6 & Schedule 4 Requirement The registered person must ensure that the home’s statement of purpose and service user guide contain all required information and are provided to residents and relatives. The registered person must ensure that medication administration records are maintained to the required standard. The registered person must ensure they and all staff complete up to date adult protection training. The registered person must ensure that a detailed plan of the home’s upgrading is submitted to the CSCI which includes the individual timescales for completion. The registered person must cease wedging doors open. The registered person must ensure that it is compliant with all fire safety regulations, including ensuring staff receive practical fire drill training. DS0000065091.V274346.R01.S.doc Timescale for action 01/06/06 2 OP9 13 06/03/06 2 OP18 12 & 13 01/07/06 3 OP19 23 01/05/06 4 5 OP19 OP19 23 23 06/03/06 01/05/06 Rushes House Version 5.1 Page 26 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. 6 Standard OP26 Regulation 16 Requirement The registered person must ensure, after consultation with the Environmental Health Department, the dining room maintains hygiene standards. The registered person must ensure staffing levels meet that set by the Residential Forum’s Care Staffing in Care Homes for Older People at all times. The registered person must ensure that the home’s rota can demonstrate all duties worked by staff and their hours of working. The registered person must ensure it has robust recruitment and selection procedures in place which are followed. The registered person must ensure that it completes a quality assurance procedures in accordance with Standard 33 and Regulation 24. The registered person must complete a full audit of residents’ finances held by the home. If deficits are evident, arrangements must be made to reimburse residents. Timescale for action 01/05/06 7 OP27 18 01/05/06 8 OP27 17 Schedule 4 7,9,19,& Schedule 4 24 01/05/06 9 OP29 06/03/06 10 OP33 01/01/07 11 OP35 20 01/06/06 Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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. 1 2 3 4 5 6 Refer to Standard OP2 OP4 OP12 OP16 OP22 OP28 Good Practice Recommendations The registered person should ensure that residents’ terms and conditions of residency are agreed and signed by the residents. The registered person should ensure that formal systems are introduced to inform residents that their assessed needs can be met by the home. The registered person should ensure that a programme of activities is developed and residents are kept informed of daily events. The registered person should ensure the home’s complaint procedure contains the required information and is provided to all residents and relatives. The registered person should ensure that parts of the home are fitted with a loop system to aid those with hearing difficulties. The registered person must ensure that 50 of staff complete NVQ training . Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Rushes House DS0000065091.V274346.R01.S.doc Version 5.1 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. 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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