Inspection on 14/01/09 for Rushey Mead Manor

This inspection was carried out on 14th January 2009.

CSCI found this care home to be providing an Poor service.

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

Rushey Mead Manor 05/10/09

Rushey Mead Manor 07/04/09

Rushey Mead Manor 10/09/08

Rushey Mead Manor 02/10/07

Rushey Mead Manor 12/12/06

Rushey Mead Manor 03/05/06

Rushey Mead Manor 18/10/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Rushey Mead Manor 30 Coatbridge Avenue Rushey Mead Leicester LE4 7ZS Lead Inspector Ruth Wood Unannounced Inspection 14th January 2009 10:45 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 Rushey Mead Manor DS0000064260.V373783.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. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushey Mead Manor Address 30 Coatbridge Avenue Rushey Mead Leicester LE4 7ZS 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) 0116 2666606 0116 2660708 Midland Healthcare Ltd Manager post vacant Care Home 40 Category(ies) of Dementia (17), Mental disorder, excluding registration, with number learning disability or dementia (17), Old age, of places not falling within any other category (40), Physical disability over 65 years of age (5) Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP may be admitted into Rushey Mead Manor where there are 40 persons of category OP already accommodated within this home. No one falling within category PD(E) may be admitted into Rushey Mead Manor where there are 5 persons of category PD(E) already accommodated within the home. No person to be admitted to Rushey Mead Manor in categories MD or DE when 17 persons in total of these categories/combined categories are already accommodated in this home. No person to be admitted to Rushey Mead Manor in categories OP, PD(E), DE or MD when 40 persons in total of these categories/combined categories are already accommodated in this home. No person who requires nursing care are to be admitted into Rushey Mead Manor in categories OP, DE, MD or PD(E) when 20 persons in total of categories/combined categories are already accommodated in this home. 10th September 2008 5. Date of last inspection Brief Description of the Service: Rushey Mead Manor is registered to accommodate forty older people in need of residential or nursing care. The home has a multicultural service user group and the staff team is also multicultural. Both English and Asian diets are catered for. There is a small temple and chapel situated in the building. Accommodation is on three floors with a lift and stairs for access. There are thirty-eight single bedrooms and one double bedroom. Two of the single bedrooms and the double bedroom have ensuite facilities. There are five lounges, two dining rooms, and one smoking room. The home is situated close to Leicester City Centre with good transport links and other local amenities. Current charges range from £331.00 to £550.00 depending on care needs and additional charges are in place for personal items such as newspapers, toiletries, and chiropody treatment. Details of what additional charges service users can expect to pay can be found in the service user guide, which is given to all service users either prior to, or on arrival at Rushey Mead Manor. A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 5 Further information about the home is available from the acting manager. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use the service experience poor outcomes. This unannounced inspection visit took place on a weekday between 10:45 and 18:15. Twenty-five people were living in the home at the time of the visit. The acting manager was present throughout the visit and we spoke to them about management and care practices within the home. We looked at all communal and most private areas of the home and directly observed various care practices, such as helping people to eat, the administration of medication and moving and handling. We spoke to three staff members about care practice and looked in detail at the care records of three people living in the home. We also spoke to four people living in the home. Records relating to staff training, recruitment and supervision were examined as well as records relating to fire safety. What the service does well: What has improved since the last inspection? Risk assessment and care planning documentation has been updated and all staff have received training in safeguarding vulnerable adults and in moving and handling. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 7 Work has been completed in improving the decoration and physical appearance of the home and is still ongoing. An up-to-date version of the service users’ guide and statement of purpose has been produced and the terms of conditions of admission and residency have been updated. 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. The summary of this inspection report can be made available in other formats on request. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 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 Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome area is good People are assessed before they move into the home to make sure their care and nursing needs can be met. The format of the service users’ guide means that not all people can access sufficient information about the home to make an informed decision about living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre-admission assessments and assessments from placing authorities were in place for the three people whose care records were looked at in detail. People and/or their relatives can look around the home and speak to the manager before making a decision to move in. New terms and conditions have been drafted and copies issued to everyone currently living in the home, these include details of the fees to be paid and outline those services available for an additional cost. The acting manager said that only eight people had signed the new documents and that she was in consultation with relatives to ensure that everyone living in the home or their representatives had signed these. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 10 We were given an up to date copy of the statement or purpose and service user guide. This was in standard written English and the acting manager confirmed that this was the only version of the guide currently available. Given the diversity of the service users currently living at the home, we would expect to see information about the home available in alternative formats, to ensure everyone has sufficient information to make an informed decision about whether the service can meet their needs. The statement of purpose describes the acting manager as the registered manager. As the Commission has not yet registered them as the manager for this home, this should be changed. The home does not provide intermediate care and therefore standard 6 is not applicable. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor Staff do not always follow care plans, which means people’s needs are not met consistently. Poor medication practice places people at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at three people’s care records in detail, directly observed their care and spoke to the manager and staff about how their care was managed. The manager has spent considerable time updating care plans (as required at the previous inspection) however work is required to ensure that staff actively use the plans, to inform the care that they deliver to people living in the home. We observed that one person had a sore on their heel, this was pointed out to the acting manager who immediately dressed the sore and removed the person’s shoes, which were found to be too tight. The person’s toes were observed to be very red. The person’s care plan included a podiatry care plan that stated the skin on their feet should be creamed daily and that between their toes should be cleaned and dried daily. Entries on daily records stated, ‘all care given’ and the person was recorded as having had a bath on 11/01/09. If the care plan had been followed then staff should had noted the Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 12 sore on the person’s heel and also noted that they did not have any suitable shoes that fitted them. This suggests that there is a discrepancy in the care outlined in plans, and that being given by care staff. The accuracy of daily records, which state ‘all care given’ is also questionable. Referrals were made to the district nurse and the podiatrist for this person during the inspection visit. The three people’s case records contained a nutritional screening tool and a record of their Body Mass Index (BMI). These had been completed a month apart. As information about BMI should inform the nutritional screening tool it is recommended that these are assessed and completed on the same date. People’s files contained evidence that they had access to optical, dental and podiatry services where appropriate. Records were in place to demonstrate that one person, who has diabetes, was having their blood glucose levels monitored and that an appointment had been made for them to see the diabetic nurse. The acting manager stated that one person in the home has a pressure sore. Records are kept of the treatment of the wound and the tissue viability nurse is involved in their care. This person (along with five others) uses an airwave mattress as part of the management of their pressure area care. On the tour of the home it was noted that one of the mattresses was set at the incorrect pressure. A record should be made of the correct pressure for every person’s airwave mattresses and this should be checked on a daily basis. Appropriate assessments were in place in relation to pressure area care and it was observed that the person with the pressure sore was moved regularly throughout the day as part of the management of their condition. Throughout the inspection visit, staff were observed to speak to people living in the home in a kind and respectful manner. This was particularly evident at lunchtime when several people required direct help in eating their food. This was provided in a sensitive way, with care staff allowing the person to dictate the pace of the activity. Care staff informed and encouraged people throughout to ensure that they received sufficient nutrition and hydration. We observed the registered nurse on duty administering medication. The nurse was observed to handle medication and place it directly into peoples’ mouths. The nurse told the inspector that they had given one person their anti–biotic tablet before they had eaten, when in fact they had forgotten to do this. The nurse signed the Medication Administration Record in the inspector’s presence to confirm that they had given this medication, in effect falsifying the record. These issues were raised with the manager at the inspection and a letter of urgent concern was sent to the responsible individual asking them to ensure that all staff administering medication are competent to do so. The response to this requirement will be monitored at the next inspection of the service. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 13 It was also observed that the nurse was forced to interrupt the administration of medication to answer several telephone calls. The manager explained that the nurse on duty had always done this, even when they was engaged in administering medication. We asked that this practice be discontinued as the distraction could compromise the ability of the nurse to safely administer medication. The acting manager consulted with the responsible individual and agreed that answering the telephone would no longer be part of the nurse on duty’s responsibility, when they were engaged in administering medication. The nurse was observed to ask people if they required pain relief before administering it and to use the appropriate thickener in drinks for people prescribed this. The acting manager has attended training relating to the implementation of the Mental Capacity Act and has subsequently completed an ‘assessment of capacity and best interest’ for several people living in the home, including those people whose records we looked at. These had been completed without consulting other people involved in the person’s care and without taking into account that capacity is dynamic rather than fixed. We discussed the validity of the assessments with the manager and she decided to remove them from the care plans. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good People enjoy a varied diet, which meets their nutritional and cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No structured activities were observed during the inspection visit but staff were observed to interact informally with residents throughout the day. Some people enjoy sitting in the reception area where they interact with people passing through. The manager said that a person sings Bhagas (Hindu devotional prayers) regularly with the Indian people who live in the home and that they have access through satellite television to Indian religious programmes and films. The activity list confirmed that this activity took place regularly. A church group also visits Christian residents, and games such as scrabble, skittles and ball are played. Seventeen of the twenty-five people currently living in the home ate lunch together in the dining room. The atmosphere was relaxed and sociable, and two visitors ate with their relatives. There are two menus served every day, a vegetarian Indian and a traditional British menu. Meals from both menus looked and smelled appetising and people appeared to enjoy their food. People who needed help to eat were supported sensitively by staff who allowed them to dictate the pace at which they ate and ensured that they received sufficient nutrition and hydration. Some people had to wait up to 40 minutes Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 15 before they received their food, because more people required support than there were staff available. Food was kept warm and no person was hurried to finish their meal. Some people choose to eat later in the day and their choice is accommodated; one person likes to make their own hot drinks and again they are able to do this. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good Good recruitment practice helps to ensure people are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff training records state that staff have received training in safeguarding vulnerable adults (several as recently as 09/01/09) and the most recently appointed staff member was able to give a reasonable account of the different ways people could be abused and also demonstrated an understanding of whistle blowing and their responsibilities under the home’s policy. Staff recruitment records contained evidence that staff had not started work at the home until a Criminal Records Bureau (CRB) check had been completed and their names had been checked against the Protection of Vulnerable Adults Register. These checks help to ensure that only suitable people work at the home. The complaints procedure forms part of the new service user guide. To ensure it is widely accessible this should be made available in alternative formats, including alternative languages for those whose first language is not English. Neither the Commission nor the home has received any complaints since the previous key inspection. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate Further improvements are needed to ensure that the home is a clean, comfortable and safe place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A considerable amount of work has taken place to improve the home’s physical environment and this was continuing during the inspection visit. We toured all areas of the home. The top corridor has been redecorated as has one lounge and the main dining room. Plans are in place to redecorate other communal areas and work was being completed on the day of the inspection to make good, damaged plaster before re-decoration took place. The acting manager said that when communal areas of the home had been completed then the redecoration of bedrooms was planned. The paintwork in many people’s rooms was grubby and there was damage to some room’s plaster. Repairs are also required to fixtures and fittings in some people’s rooms, one person’s en-suite did not have a toilet seat, the light and extractor fan in another person’s en-suite was Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 18 not working and the chest of drawers in another person’s room needed repairing. It is recommended that a system be put in place to ensure that such repairs are identified and acted upon, routinely and quickly. All communal areas of the home were clean and tidy but there was a smell of urine in two rooms. This was brought to the attention of the manager who arranged for the carpets to be cleaned. Some toilets did not have liquid soap in the fitted soap dispensers and in some toilets paper towel dispensers had not been fitted, so towels were placed on top of toilet cisterns. Staff records indicated that staff have received training in infection control and they were observed to use gloves and aprons as appropriate. ‘Danicentres’ which hold gloves, aprons and alcohol gel are situated on each floor for staff to use. Action is required in some areas to ensure the health and safety of people living in the home. Large areas of the home are unused; this includes kitchens, communal rooms and bedrooms. Given that the home is registered to provide care for people with dementia the registered person must make sure that all these areas are safe and secure and cannot be inadvertently accessed by people living in the home. Two laundry cupboards, which should be kept locked, were open; these must be kept locked. A large jug of green liquid (later identified as cleaning fluid for the carpet cleaning machine) was found unattended in a person’s bedroom. The registered person must ensure that all potentially dangerous substances are locked away when not in use. We found that all radiators in the home were covered, except for one in the downstairs bathroom. An urgent requirement was made and the responsible individual has informed the Commission that the radiator was covered on 16/01/09. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good Staff receive appropriate training to inform their work in meeting people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff’s records were looked at. All three contained evidence that Criminal Records Bureau checks and two written references had been obtained for each staff member before they started work in the home. Their names had also been checked against the Protection of Vulnerable Adults register. Discussion with a recently appointed staff member confirmed that recruitment checks had taken place before they had been appointed. All staff files contained an induction manual and a separate checklist relating to health and safety in the home. The recently appointed staff member confirmed that they were currently on induction and were working alongside more experienced members of staff. The staff member, as part of their induction had received training in moving and handling and in safeguarding vulnerable adults. Staff have the opportunity to undertake National Vocational Training in care and domestic and catering staff also study for these vocational qualifications. Three staff have undertaken a distance-learning course in dementia care; the registered manager said that this course would be made available to all staff, to ensure that they have the necessary skills to meet people’s needs. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 20 Some people living in the home had to wait a long time for their meal at lunchtime because more people needed support with eating than there were staff available to help them. Staffing levels should therefore be reviewed to ensure that there are always sufficient staff on duty during times of peak activity. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate The health, safety and welfare of people living in the home is not always promoted or protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has been in post since April 2008 and has submitted an application to the Commission for registration. She is a registered nurse and has seventeen years experience in care management. She has recently attended training in several key areas, including safeguarding and implementation of the Mental Capacity Act. Further work is required so that there is a robust quality assurance system in place to ensure that the service is consistently run in the best interests of the people living in the home. The acting manager has sent out questionnaires to some relatives but the information obtained from these has not been collated and neither are there formal processes in place to obtain the views of the Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 22 people living in the home or of other stakeholders such as commissioning social workers. Arrangements for safeguarding the management of people’s finances are in place and discussed with the acting manager. Records and receipts are kept of all transactions. Documentary evidence was seen, that all staff currently working in the home have received recent training in moving and handling and this was confirmed through speaking to staff members. However poor practice was observed on two occasions. Firstly where one person was moved in a wheelchair without footplates being in place and secondly when a person was transferred from an armchair to a wheelchair and the brakes were not put on the wheelchair. Poor practice was also observed in the administration of medication, despite staff members having received appropriate training (please see Health and Personal Care). Records show that staff do receive regular supervision meetings but it is recommended that supervision also includes regular, observation of staff practice to ensure their ongoing competency in key areas. This is particularly important for staff recently appointed. All staff have completed a distance-learning course in health and safety and the majority of staff have completed training in food hygiene. Two concerns about staff’s response to health and safety practice were identified, firstly that fire doors meant to be locked were not and secondly that a potentially dangerous substance was left unattended in a person’s bedroom. Fire safety records demonstrate that equipment and systems have been serviced and are regularly tested. The fire risk assessment in place should be reviewed and updated if necessary. Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 23 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 3 X X X 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that people’s care, as outlined in their care plans, is delivered by all staff. This is to ensure that all people living in the home, consistently receive the correct care to meet their needs. The registered person must ensure that daily records accurately reflect the care given to people living in the home. This is to ensure that people’s health and care needs can be accurately monitored and updated when necessary. 3. OP9 13 (2) The registered person shall make 26/01/09 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. The registered person must ensure that accurate records are kept of all medication administered to service users to Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 25 Timescale for action 28/02/09 2. OP7 17 06/02/09 ensure that medication is administered safely, correctly and as prescribed. This is to ensure that there is a clear record of when residents have received medication, to prevent medication being omitted, or being given again in error. (Previous timescale of 24/09/08 not met) The registered person must ensure that all staff administering medication are competent to do so. This is to ensure that residents receive the correct medication, in a safe manner at the appropriate time. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. 4. OP9 13(2) 26/01/09 5. OP9 12(a) 31/03/09 6. OP19 13 (4) The registered person must ensure that all relevant professional bodies and other parties are involved when decisions are made regarding a service users mental capacity. (Previous timescale of 01/10/08 not met). The registered person must 06/02/09 ensure that all areas of the home not currently used, are made safe and/or secure. This is to ensure that people living in the home do not inadvertently enter these areas, placing themselves at risk. The registered person shall 31/03/09 having regard to the number and DS0000064260.V373783.R01.S.doc Version 5.2 Page 26 7. OP19 23(2)(b) (d) Rushey Mead Manor needs of the service users ensure thatThe premises to be used are kept in a good state of repair externally and internally. All parts of the care home are kept clean and reasonably decorated. The registered person must ensure that service users are provided with a comfortable and homely place to live. (Previous timescale of 01/12/08 not met) All fire doors designated as requiring to be kept locked must be kept locked. This is to ensure the ongoing welfare and safety of all those living and working in the building. The registered person must ensure that all potentially dangerous substances are locked away when not in use. 8. OP19 13 (4) 14/01/09 9. OP38 13 (4) 14/01/09 10. OP38 13(5) This is to ensure that people living in the home are not exposed to unnecessary risks. The registered person shall make 06/02/09 suitable arrangements to provide a safe system for moving and handling service users. The registered person must ensure that staff move and handle service users in an appropriate and safe manner. Previous timescale of 19/09/08 not met Rushey Mead Manor DS0000064260.V373783.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. 1. Refer to Standard OP1 Good Practice Recommendations The service users’ guide should be available in different formats to take account of the different languages spoken by people living in the home and the communication difficulties that some people may experience because of dementia. The information in the statement of purpose must accurately reflect the registration status of the current acting manager. It is recommended that a person’s body mass index should be calculated on the same day as the nutritional screening tool. A record should be made of the correct pressure for every person’s airwave mattresses and the pressure level should be checked on a daily basis. A system should be put in place to ensure that any repairs to furniture, fittings or equipment are identified and acted upon routinely and quickly. Staffing levels should therefore be reviewed to ensure that there are always sufficient staff on duty, during times of peak activity. A quality assurance system should be developed which seeks to gain the views of the people who live in the home, as well as the views of their relatives and other stakeholders. These views should then inform the operation and development of the service Staff supervision should include regular, observation of staff practice to ensure their ongoing competency in key areas. The fire risk assessment in place should be reviewed and updated if necessary. 2. 3. 4. 5. 6. 7. OP1 OP8 OP8 OP19 OP27 OP33 8. 9. OP36 OP38 Rushey Mead Manor DS0000064260.V373783.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Rushey Mead Manor DS0000064260.V373783.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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