Inspection on 10/07/07 for Rushymead

This inspection was carried out on 10th July 2007.

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

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

Other inspections for this house

Rushymead 04/06/09

Rushymead 01/07/08

Rushymead 19/07/06

Rushymead 28/11/05

Rushymead 16/05/05

Rushymead 05/01/05

Rushymead 20/09/04

Rushymead 12/02/04

Rushymead 15/09/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Rushymead Tower Road Coleshill Amersham Bucks HP7 0LA Lead Inspector Chris Sidwell Unannounced Inspection 10th July 2007 10:30 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 Rushymead DS0000023016.V338845.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. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushymead Address Tower Road Coleshill Amersham Bucks HP7 0LA 01494 727738 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) rushymead@aol.com The Michael Batt Charitable Trust Hilary Mitchell Care Home 28 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (28) of places Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: Rushymead is a care home providing personal care and accommodation for twenty older people with physical frailties and eight with mental frailties. The Michael Batt Charitable Trust owns the home, which is a registered charity. The home has an established senior team and appears to have a good relationship with the general practitioner and district nursing services. The home is located in the village of Coleshill some two miles south of Amersham. Public transport and local amenities are not easily accessible. The building has been adapted for use as a residential care home for over twenty years. It was first registered in 1991. It consists of three floors ground, first and second floor. There are twenty-six single rooms and one double room. Five bedrooms have en suite facilities. There is a passenger lift. On the day of the inspection there were twenty-seven residents living in the home. The home has extensive, well maintained gardens. The current scale of charges range from £580.00-£695.00 per week. Additional charges are made for chiropody, hairdressing, newspapers, toiletries and optical services. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over the course of three days and included a one day unannounced visit to the home. The key standards for older people’s services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit, a questionnaire was sent to the manager, with questionnaires for distribution to residents, relatives and visiting professionals. Twelve residents and family members returned the questionnaires, as did three general practitioners. Residents and families were also spoken to on the day of the unannounced visit. Discussions took place with the manager, care and ancillary staff. Care practice was observed. A tour of the premises and examination of some of the required records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well: The care needs of potential residents are identified with them, prior to their move to the home, to ensure that they can be met. One family member said that the home ‘provides a family setting and is homely and comfortable’. The standard of care is good although the care planning could be improved and staffing levels should be monitored. One family member said that ‘I am pleased with the care offered and feel fortunate to have my relative at Rushymead’. Medication is managed well. The general practitioners who returned the questionnaires said that the care was of a good standard. In general residents have a choice as to how they spend their day and a range of activities are on offer to bring interest and diversion to the day. The standard of food is good and residents’ nutritional needs are met in a pleasant environment. One family member said that ‘the food always looks appetising and there is variety’. There are complaints policies and procedures in place and residents and families are confident that their concerns will be listened to and addressed. Residents are protected from potential abuse. The home is elegant and set in well-maintained gardens. There is an ongoing programme of decoration. Residents’ rooms vary in size and are homely. There was an offensive odour in one room but not in the home as a whole. There are sufficient staff with basic skills to meet residents’ needs. Recruitment procedures are thorough and checks on the potential staff member’s identity, work history, references and criminal records bureau disclosures are made before the staff member starts work. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 6 There is an experienced manager who with the support of the Trustees is implementing a quality assurance programme. The view of residents and their families are sought and taken into account in the management of the home. What has improved since the last inspection? What they could do better: The registered manager must ensure that residents have a care plan that is current and reflects their needs. Care plans must be reviewed monthly. Regular audit of care plans should be undertaken to ensure that they contain the detail required to ensure that care staff are fully aware of residents’ needs. All residents should be assessed as to their risk of developing pressure damage, nutritional deficiency and of falling. The floor tiles in the conservatory are worn and should be replaced. The control of infection policies and procedures must be updated in line with guidance issued by the Department of Health in June 2006 and available on their website www.dh.gov.uk. The offensive odours in some areas of the home should be eliminated. Staffing levels should be monitored carefully to ensure that residents care needs can be met and that they can be supervised when in the lounges. A training matrix must be developed and updated to demonstrate that staff have had the basic mandatory training in safe working practices. All staff should have dementia care training. Please contact the provider for advice of actions taken in response to this Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 7 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. Rushymead DS0000023016.V338845.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 Rushymead DS0000023016.V338845.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): 2, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The care needs of potential residents are identified with them, prior to their move to the home, to ensure that they can be met. EVIDENCE: The files of three residents were examined. All had evidence that the manager or senior nurse had visited them prior to their move to the home and their needs had been assessed. The residents spoken to said that they had received enough information about the home before they moved and had had the opportunity to visit or stay for a short period prior to moving. Most said that friends or their doctor had recommended the home. They were happy with the information that they had been given and said that the staff had worked hard to make the move as easy and comfortable as possible. There were copies in the file of care manager’s reviews where appropriate The documentation used to guide the assessment of potential residents who are self funding is comprehensive. There is reference to potential residents’ religious and cultural needs. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 10 All residents have a contract, which meets the National Minimum Standards, and there was evidence in the files to show that residents had been given notice of fee increases. There is reference to potential residents’ religious and cultural needs. The home does not offer intermediate care. Rushymead DS0000023016.V338845.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 and 11 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. In general residents personal, healthcare and medication needs are met although the standard of care planning has only marginally improved since the last inspection and should be addressed. EVIDENCE: The home uses the Standex care planning system. Three care plans were examined. The standard of record keeping has improved since the last inspection but is still not complete. The manager had initiated regular audit of the standard of record keeping although this had not been undertaken recently. Not all had risk assessments and none of those seen had pressure damage risk assessments. The social activity and personal care sheets were not adequately maintained. Care plans were not updated monthly. Daily entries were made and dated. These detailed the care given but did not say to what extent the care plan was being followed or the goals achieved. The care plans seen had last been updated in June 2006. One resident’s care plan had not been updated since then, despite a spell in hospital. A requirement was made at the last inspection that the registered manager should ensure that all Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 12 residents have a care plan that is current and reflects their needs. The care plans should be updated when necessary and at least monthly. This has not yet been achieved. The requirement will be repeated in this report and a new timescale for achievement set. A regular programme of care plan audits should be implemented. The home’s staff maintain the personal and oral hygiene care of residents. Those residents who are able to are supported by staff to maintain their independence and be self-caring. It was noted that the older people specialist nurse was supporting the home’s staff. Not all the plans seen had evidence that the residents risk of acquiring pressure damage had been assessed, although no residents had pressure damage at the time of the unannounced visit. Aids and equipment to prevent pressure damage is available. There was no evidence of formal nutritional risk assessments in the files seen although residents are weighed monthly and their weights were seen to be stable. Residents with poor appetites were having their food and fluid intake monitored and were having additional supplements such as, smoothies and milk shakes. The community dietician had visited the home and provided staff with nutritional advice. Residents had drinks within reach. Residents spoken to said that they were able to access dental, optical and chiropody treatment when required. There was evidence in the files that the General Practitioner visited the home regularly. Medication management has improved since the last inspection. There are medication policies in place. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. Controlled drugs were stored in a satisfactory manner and all entries to the controlled drug register were signed. A staff member spoken to said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision the doctor and family would be informed and a way forward agreed. The staff were observed to be treating the residents with respect and their dignity was protected. All care is given in resident’s rooms. Families confirmed this. Residents may have a telephone to use in the privacy of their own rooms. All residents wear their own clothes. The residents seen had had their hair dressed and were assisted to dress well and maintain their personal hygiene and appearance. One lady said ‘this is important to me’. The relatives and resident who returned the questionnaires and those spoken to on the day of he unannounced visit said that care staff always or usually met their needs. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 13 The manager said that the home could care for people at the end of their life if that is their wish. There were a number of ‘thank you’ letters from relatives thanking the staff for the care they had given their relatives at the end of their life. The manager said that she would be linking with the recent National Health Service ‘End of Life’ programme to ensure that the standards of palliative care offered in the home are up to date. Rushymead DS0000023016.V338845.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 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. In general residents have a choice as to how they spend their day and a range of activities are on offer to bring interest and diversion to the day. The standard of food is good and residents’ nutritional needs are met in a pleasant environment. EVIDENCE: There is an activities coordinator in post who arranges regular activities, which residents can participate in if they wish. Residents are encouraged and supported to maintain links with their local community and one resident was using dial a ride to visit her local church group on the day of the unannounced visit to the home. Most residents spoken to felt that the routines were flexible although one, when asked ‘do staff listen or act upon what you say’ said ‘No, they work to a given set of rules’. This must be guarded against and residents wishes taken into account at all times. There are no restrictions on visiting and the residents spoken to said that they could see friends and family whenever they wished. Information about local advocacy services is posted on the notice boards. Residents are encouraged to bring personal possessions with them when they move and many had chosen to do so. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 15 The standard of food is good. The residents said that they had a choice of main meal. One resident said that the ‘food is good and there is plenty of it’. There is a varied menu and special diets can be offered when necessary. There was no one in need of special diet on religious or cultural grounds at the time of the inspection although the manager said that these could be provided if necessary. Mealtimes were observed to be a sociable occasion and residents could choose whether they ate in the dining room or in their rooms. There are three full meals a day and snacks can be offered in the evenings, if necessary. Rushymead DS0000023016.V338845.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 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There are complaints policies and procedures in place and residents and families are confident that their concerns will be listened to and addressed. Residents are protected from potential abuse. EVIDENCE: There are complaints policies and procedures in place. A complaints log is kept and action was seen to be taken in response to concerns and complaints. The resident and family members who returned the questionnaires said that they knew who to speak to if they were unhappy and that the home responded appropriately. One family member said, in relation to complaints, ‘it doesn’t happen often but anything I do raise is dealt with quickly’. The home is aware of the local multi-agency strategy for the Protection of Vulnerable Adults and staff have had training in this topic since the last inspection. The Commission for Social Care Inspection for Social Care Inspection has not received any complaints and has not been notified of any referrals made to the local authority under their safeguarding procedures. Rushymead DS0000023016.V338845.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, 24 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. In general the home is well maintained, set in attractive gardens and residents’ rooms are homely and comfortable. There is a need to update infection control practices and repair the conservatory floor to further protect residents from potential harm. EVIDENCE: The home is set in secluded grounds and has been adapted for its present use. It is well maintained and there is a programme of ongoing refurbishment. The grounds are attractive and accessible to people who use wheelchairs. A requirement was made at the last inspection that the conservatory tiles be replaced. This has not yet been achieved although the manager said that there were plans to do this. The loose tiles have been secured with hazard marking tape to minimise the potential trip hazard. The gate and front entrance of the home is secure and access cannot be obtained without ringing the bell. Residents can come and go as they please. Although the home is registered Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 18 for the care of people with dementia the manager said that they would not be able to meet the needs of any one who was prone to wandering, as their security could not be assured without restricting the freedom of other residents. There are no CCTV cameras. Residents’ rooms vary in size. Some have ensuite facilities. Residents are encouraged to bring small items of furniture and personal belongings when they move to personalise their rooms and many had chosen to do so. The home is homely and comfortable. There is guidance on infection control in place, although the infection control policies and procedures have not been updated in line with guidance issued by the Department of Health in June 2006. Not all staff have received infection control training. This must be addressed. There was an offensive odour in one room but not in the home as a whole. This should also be addressed. The laundry was clean and tidy on the day of the unannounced visit. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There are sufficient staff with basic skills to meet residents’ needs. The recruitment procedures have improved and protect residents from unsuitable carers. There is a need for staff to have dementia care training if they are to meet residents’ needs fully. EVIDENCE: There are five members of staff on duty in the morning, four in the afternoon and three at night. An additional member of staff is on duty between 6pm and 10pm. This means that there is a minimum of one person on each floor with one or two people floating. The staff spoken to said that they could always get help but that they were anxious that they could not always meet residents needs in a timely manner and if a resident needed care in their rooms this may mean that residents in the lounge would not be supervised sufficiently. Given that the home is registered for up to eight people with dementia who have high care needs and twelve people were identified on the pre inspection questionnaire as needing two or more staff to help with their care, these staffing levels must be monitored carefully to ensure that residents needs are met in a timely way and residents are supervised regularly when in the lounges. The manager should also agree with the Trustees the steps that she should take if she feels that additional staffing is needed on a short-term basis if resident’s dependency increases. Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 20 There are training programmes in place. Fifty percent of staff hold the National Vocational Qualifications in Care at level 2. There was evidence in the files to show that staff have had an induction programme. Records of staff training are held in individual staff records. It is recommended that the manager develop a training matrix as a management tool in order that she can check that all staff have had the required mandatory training with annual updates as necessary. Not all staff have had dementia care training, which should be undertaken as a priority. The recruitment files of three recently recruited staff were examined. All held the required information to verify the person’s identity and contained an up to date photograph of the employee. Two references and Criminal Records Bureau disclosures had been sought before the staff member started work. An application form had been completed and interview records had been kept. Copies of training certificates were on file. Rushymead DS0000023016.V338845.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 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home is well managed for the benefit of residents. Quality monitoring systems, which take into account the views of residents and their families, are being implemented. EVIDENCE: There is an experienced manager in post. She has registered with the Commission for Social Care Inspection. The staff spoken to said that they had confidence in the manager and that the atmosphere within the home was open and supportive. The manager has completed the National Vocational Qualifications in Management at level 4. She is a qualified nurse. A quality assurance programme has been identified since the last inspection and is being implemented. The manager expects this to be fully implemented Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 22 by the end of this financial year. A questionnaire has been developed and distributed for residents, families and other interested parties (e.g. health professionals, care managers). These results of these have been analysed and action taken in response to residents wishes. One of the Trustees undertakes monthly quality assurance visits in line with Regulation 26 of the Care Homes Regulations 2001 and records of these are kept at the home. Most of the requirements of the previous inspection report have been addressed although not all. These have been restated in this report and new timescales for completion set. The home does not manage residents’ finances on their behalf. A small amount of personal allowance to cover everyday items may be kept for safekeeping. Records are kept. Receipts are given for all monies received and expenditure paid out on behalf of individual residents. The records were checked and found to be correct. There are health and safety policies and procedures in place. The individual staff records seen showed that staff had received the mandatory health and safety training, including moving and handling, food hygiene, fire safety and infection control. It was not possible to verify that all staff had this training, as an overall training matrix was not available. This should be established. The fire safety log was examined. A fire risk assessment is in place. The staff spoken to were aware of the fire evacuation policy and a fire drill had been held on 16th may 2007. Fire safety equipment is tested on a regular basis. An accident book is maintained. The pre inspection questionnaire stated that all annual maintenance of services had been undertaken and the home held certificates and invoices to verify this. Rushymead DS0000023016.V338845.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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Rushymead DS0000023016.V338845.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(1) Requirement The registered manager must ensure that residents have a care plan that is current and reflects their needs. Care plans must be reviewed monthly. This is an unmet requirement of the previous inspection and a new timescale has been set. All residents should be assessed as to their risk of developing pressure damage, nutritional deficiency and of falling. The floor tiles must be replaced in the conservatory. This is an unmet requirement of the previous inspection and a new timescale has been set. The control of infection policies and procedures must be updated in line with guidance issued by the Department of Health in June 2006 and available on their website www.dh.gov.uk There must be no offensive odours in the home. The registered manager must ensure that mandatory training DS0000023016.V338845.R01.S.doc Timescale for action 31/10/07 2 OP8 12(1)(a) 31/10/07 3 OP19 23(2)(b) 31/12/07 4 OP26 13(3) 31/10/07 5 6 OP26 OP30 16(2)(k) 18(c)(i) 30/08/07 31/10/07 Rushymead Version 5.2 Page 25 7 OP30 18(1)(a) for all staff is kept updated. This is an unmet requirement of the previous inspection and a new timescale has been set. All staff should have dementia care training. 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP11 Good Practice Recommendations The manager should contact the ‘End of Life care coordinator in the local Primary Care Trust to ensure that the standard of care the home provides is up to date and meets best practice standards in the field. The manager should agree with the Trustees the steps that she should take if staffing levels need to be increased to meet residents’ needs. The quality assurance system should be fully implemented. 2 3 OP27 OP33 Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Rushymead DS0000023016.V338845.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!