Inspection on 19/07/06 for Rushymead

This inspection was carried out on 19th July 2006.

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

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

Other inspections for this house

Rushymead 04/06/09

Rushymead 01/07/08

Rushymead 10/07/07

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 OLA Lead Inspector Joan Browne Unannounced Inspection 09:30 19 & 31st July 2006 th 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 DS0000023016.V295425.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. DS0000023016.V295425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushymead Address Tower Road Coleshill Amersham Bucks HP7 OLA 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 DS0000023016.V295425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 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 gardens that are well maintained. The current scale of charges range from £570.00-£689.00 per week. Additional charges are made for chiropody, hairdressing, newspapers, toiletries and optical services. DS0000023016.V295425.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of two days. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of the previous inspection noted. Comment cards were received from five residents, nine relatives, one health and social care professional and two general practitioners. Overall they were satisfied with the care that was being provided. A tour of the premises was undertaken and care documentation and records were examined. Residents and staff were spoken to. The care of four residents was ‘case tracked’. Care practices and the home’s approach to quality and diversity issues were observed. What the service does well: What has improved since the last inspection? What they could do better: The home must be consistent and ensure that all prospective residents are assessed prior to moving into the home to ensure that their care needs would be fully met. The home must ensure that residents have a care plan, which is current and reflects their needs. Plans must be reviewed monthly. DS0000023016.V295425.R01.S.doc Version 5.2 Page 6 Staff’s practice in the administration and recording of medication must be improved to ensure that residents’ medication needs are to be met safely. Maintenance and housekeeping issues identified during the inspection must be addressed to ensure that residents continue to live in a safe and wellmaintained environment. The home’s recruitment procedure needs to be strengthened to ensure that all staff complete an application form as part of the recruitment process and have an up to date photograph on file to confirm proof of identity. The home must ensure that mandatory training for staff is regularly updated to ensure that competent staff care for residents. The home must develop an effective quality assurance system to ensure that it is run in the best interest of residents and to continue and improve on the care that is provided. Electrical leads in bedrooms that pose a trip hazard must be risk assessed to minimize any potential risks. An improvement plan must be submitted to the Commission in response to the requirements and recommendations made in this report. 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. DS0000023016.V295425.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000023016.V295425.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs to be consistent and ensure that all prospective residents are assessed prior to admission to ensure that individuals’ needs would be fully met. EVIDENCE: The home has a comprehensive assessment tool in place and aims to ensure that all prospective residents are assessed before admission to the home. However, it was noted that the home did not carry out an assessment for a resident that was recently admitted to the home. It is required that the home is consistent and ensures that all residents are assessed before being admitted to the home to ensure that their care needs would be fully met. DS0000023016.V295425.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs to ensure that residents’ care plans are current, reflect their needs and reviewed monthly. Staff’s practice in the administration and recording of medication needs to be improved to ensure that residents’ medication needs are to be met safely. EVIDENCE: The home uses the Standex care planning system. Four care plan files were examined. The standard of record keeping was variable. Some sections of the front sheet of the record had not been completed. The social activity and personal care sheets were not adequately maintained. Some entries recorded were not clear and gaps were noted. In one particular resident’s care plan the long- term care needs lacked detailed information. It was noted that the individual had a history of depression and at times presented challenging behaviour. There was no care plan in place relating to the individual’s behaviour. It was not evident if any specialist support had been sought for the individual such as, input from the community psychiatric nurse. In a second care plan it was indicated that the individual should have their feet elevated when sitting out. It was noted that the plan was not being followed for the DS0000023016.V295425.R01.S.doc Version 5.2 Page 10 individual’s feet were not elevated when sitting out. Care plans should be followed to ensure that individual’s needs are being met. It is acknowledged that there has been an improvement in the detailing of information in the night care plans. However, the frequency of night checks in some individuals’ care plans were described as regular. Checks should be clearly described for example, hourly or two hourly. Daily records were predominantly orientated towards recording physical care provided and eating and drinking. Clarity in the daily report sheets was compromised by scribbled out and written over entries. Care should be taken to ensure entries are legible. The language used in some entries to describe residents’ actions was not always appropriate. For example, the following entry was noted in a particular resident’s daily log: ‘X grumbled about lunch.’ The home aims to review care plans monthly but had failed to achieve this in the records examined. It is required that care plans are reviewed monthly. Regular auditing of care plans would provide the management team with the appropriate information that is needed to train staff in care plan content and recording practice. 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. All residents’ weights and moving and handling risk assessments had been recently reviewed. Waterlow assessments for those residents at risk of tissue damage had been carried out. Those residents presenting risk of tissue damage had been supplied with aids and equipment such as mattresses and pressure relieving cushions to reduce the risk of tissue damage. The home had also purchased additional sliding sheets, belts and slings for the hoists. Residents with poor appetites were having their food and fluid intake monitored closely and was having additional supplements such as, smoothies and milk shakes. The community dietician visited the home and provided staff with nutritional advice. Further visits were being arranged. Residents spoken to said that they were able to access dental, optical and chiropody treatment when required. Treatment from the National Health Service can be obtained via a referral from their general practitioner. The medication administration record (MAR) sheets were examined and some inconsistencies and weaknesses in staff’s recording practice persist. These were scribbled over entries and handwritten entries on MAR sheets not dated and signed by two staff members. It was also noted that a particular medication was recorded on the MAR sheet with limited instruction. The information recorded was as follows: ‘apply to the affected area as directed.’ As a good practice prescribed medication should have clear instructions on its use to avoid errors with its administration. It was noted that lactulose liquid DS0000023016.V295425.R01.S.doc Version 5.2 Page 11 bottles were sticky. Staff should ensure that bottles are wiped with a damp cloth after use. It was noted that a particular medication that was due at 21.00 pm had been signed for before it was due. Staff’s practice in the administration and recording of medication should be regularly assessed to ensure that medication is administered appropriately. It is acknowledged that the home now has an audit system in place and MAR sheets are regularly audited. The practice of storing non-medication items in the medication cupboards should cease. It was also noted that the keys for the medication cupboards were placed on top of the medication cupboards rather than carried by staff members. This practice is unacceptable and should be ceased. Three residents were prescribed for controlled medication. The controlled drug register was completed correctly. It was noted that there was detailed information recorded in some individuals’ care plans for the administration of Forsamax medication, which is given weekly for the treatment of osteoarthritis. This is deemed as good practice. Residents spoken to said that staff respected their privacy. Personal care and medical examinations are carried out in residents’ bedrooms. Residents’ wear their own clothes and were appropriately dressed with attention to detail. There were no residents with shared rooms at the time of the inspection. Residents’ preferred term of address was recorded in the care plans. DS0000023016.V295425.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents’ social, recreational and dietary needs were being adequately met. EVIDENCE: Residents spoken to confirmed that the home’s routine was flexible and matched their expectations. One particular resident would like to have more activities provided. Others said that they felt safe living in the home. Those spoken to did not wish to be involved in the decision making within the home. The home has an activity organiser who provides activities three days a week. Entertainers and theatrical presentations are booked to entertain residents in the home. Residents are also given the opportunity to attend the Christmas pantomime at the local theatre. Several outings in the community had taken place such as pub lunches, visits to national parks and gardens and more had been planned. A summer barbecue for residents and relatives was due to take place. Residents confirmed that they are able to maintain links with their family and friends. The home does not have any restrictions on visiting. Those spoken to DS0000023016.V295425.R01.S.doc Version 5.2 Page 13 confirmed that staff made their visitors feel welcome. A lay preacher visits the home weekly. The local Brownie group is also a regular visitor to the home. One particular resident spoken to was able to maintain links with her local church and is able to access the services of dial a ride several times a week to attend prayer meetings. Two residents were looking after their own financial affairs. One resident was using the services of an advocate. Residents are made aware that they are able to bring in small items of furniture such as a chair or dressing table if they wished to. Some rooms were personalised with items of furniture, pictures and mementoes. Residents and their representatives are made aware that they can request to have access to their personal records. The manager confirmed that one particular resident’s representative has regular access to their care plan. It was noted that the filing cabinets on the units where individuals’ care plans are stored were not locked. Staff are reminded that the filing cabinets should be kept locked to ensure confidentiality is not breached. Residents confirmed that they are provided with three meals daily. Hot and cold drinks and snacks are available throughout the day. One particular relative commented that there had been an improvement in the quality of the food. It was noted in some care plans examined that information relating to individuals’ preferences was detailed. Lunch was observed on one unit. Choices on offer were lamb chops, chicken curry, rice, mashed potatoes and vegetables. Residents spoken to were complimentary about the food and made the following comments: ‘The food is excellent’. ‘The food is good.’ The home has had support and advice from the community dietician. Smoothie drinks and milk shakes are prepared daily for those residents with poor appetites. Cakes are prepared daily and served mid-afternoon with hot drinks of residents’ choice. The manager said that arrangements were being made for the chef to support the care staff and assist with the serving of meals at lunchtime to ensure that the meals are presented attractively and are appealing to the residents. The home now has two sittings at teatime to ensure that those residents who need assistance with feeding are given adequate time and assistance to enjoy their tea in a relaxed atmosphere. DS0000023016.V295425.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has a complaints procedure in place, which residents and relatives were confident with. Staff’s knowledge in the protection of vulnerable adults was limited and would need to be updated regularly to ensure that they are competent to protect residents from any potential abuse. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The home also indicated on its pre-inspection questionnaire that it had not received any complaints about the service. There was a concern raised by a health care worker about care practice in the home. The concern was dealt with appropriately and the home’s staff are now receiving support from other health care professionals to improve on their care practice and the care provision. The manager was appreciative of the support that the home had received from the community project nurse and other health care professionals. Residents spoken to said that they were aware of whom to talk to if they had to make a complaint. They were confident that complaints are listened to and taken seriously. The home has procedures in place for responding to suspicion or evidence of abuse. However, there were some gaps in staff’s knowledge of this subject. The home’s training matrix highlighted that a large number of care staff DS0000023016.V295425.R01.S.doc Version 5.2 Page 15 including senior staff had not received updated training in the protection of vulnerable adults. It is required that staff must undergo updated training in the protection of vulnerable adults to enhance their knowledge. DS0000023016.V295425.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Overall the house is well maintained. However, maintenance and housekeeping issues identified during the inspection would need to be addressed to ensure that residents continue to live in a safe and well-maintained environment. EVIDENCE: The home has been adapted as a residential home and appears suitable for its purpose. Lounges, toilets, bathrooms and corridors have recently been redecorated. The pre-inspection record identified that all planned decoration had been completed. Protectors had been fitted to doors and corners in the corridor on the first floor to prevent damage to the paintwork from trolleys and wheelchairs. Residents’ bedrooms viewed were personalised and were clean and tidy. The grounds were tidy and are safe for residents to use. One particular resident that is a wheelchair user was able to spend time in the garden independently enjoying the wild life. DS0000023016.V295425.R01.S.doc Version 5.2 Page 17 The home has not had a recent visit from the local fire service. However, it has had a visit from the local environmental health service. All matters relating to food handling and hygiene were found to be satisfactory. A silver award was presented to the home in recognition for maintaining good food standards. During a tour of the building the following maintenance and housekeeping issues were identified as needing attention: • • • • Ceiling lights in areas of the building contained dead insects and required cleaning Condensation was noted in one of the double glazed windows in the conservatory- The seal in the window should be checked and replaced if required The floor tiles in the conservatory were chipped and worn in some areas and needed to be replaced The carpet on Windsor unit was worn in areas and needed to be replaced The home was clean and tidy on the day of the inspection. The laundry is situated away from the kitchen and was clean and tidy. The floor and walls in the laundry room are impermeable. There is a red bag system in place for separating soiled linen to reduce the risk of cross infection. The system was in the process of being updated. Some staff have had training in infection control. Hand washing facilities are available. DS0000023016.V295425.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home’s recruitment process needs to be strengthened to ensure that all staff complete an application form as part of the recruitment process and have an up to date photograph on file to confirm proof of identity. Records relating to staff training need to be maintained to ensure that training is current. EVIDENCE: The home was adequately covered on the day of the inspection. There were five staff allocated to work on three units. This number included the team lead who was leading the shift. The manager and deputy manager were supernumerary to the rota. In the afternoon the number is reduced to four staff. The staffing hours were recently reviewed to meet the dependency levels of the residents. There were a considerable number of residents who required two staff members to assist with moving and handling. Between the hours of 18.00 pm- 22.00 pm there is now an extra member of staff. Three carers cover the night shift. The home would need to ensure that residents’ dependency levels are reviewed regularly to ensure that there are sufficient staff to meet residents’ needs. Residents spoken to felt that staff were always available to help them. Two members of staff spoken to felt that since the increase of staff numbers in the evening there is now more time to care for residents. The home employs nineteen care staff. Eight staff have achieved the national vocational qualification (NVQ) in care at level 2 and a further six are DS0000023016.V295425.R01.S.doc Version 5.2 Page 19 undertaking the award. The home is working towards meeting the standard that 50 of all staff hold the NVQ in care at level 2. The recruitment records for the two most recently appointed staff members were examined. Criminal record bureau clearance checks were obtained. There were two references obtained, one from the previous employer. However, a completed application form was not in place for one of the personnel. There were no recent photographs available to confirm proof of individuals’ identity. Health declaration and fitness of health statements were in place and terms and conditions of employment. New staff are now undertaking a ‘Skills for Care’ accredited induction programme. The training matrix seen highlighted that not all care staff had updated mandatory training in first aid, food handling and hygiene, health and safety. It was noted that some staff had not had training in the protection of vulnerable adults. The manager confirmed that staff have had training in dementia and challenging behaviour. The home’s training matrix seen did not reflect this and would need to be amended. DS0000023016.V295425.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs to develop an effective quality assurance system to ensure that it is run in the best interest of residents. Electrical leads in bedrooms that pose a trip hazard should be risk assessed to minimize any potential risks. EVIDENCE: Since the last inspection there has been a change of manager. The previous manager retired and the project manager is now the registered manager. A deputy manager, six team leaders and four senior carers support the manager. The manager and the deputy manager are working towards achieving the national vocational qualification in care at level 4. The staff said that the management atmosphere was open and that their views were listened to. DS0000023016.V295425.R01.S.doc Version 5.2 Page 21 The home looks after some residents’ personal allowances. There are systems in place to ensure that residents’ money is handled appropriately. Each resident has a written transaction sheet, which is maintained by the home’s administrator. At the last inspection a requirement was set for the home to develop a quality assurance survey to seek the views of residents and relatives about the service delivery. This requirement has not been met and is being repeated. It is acknowledged that work was in progress for the survey to be carried out. The manager said that internal self- auditing systems were also being developed to enhance the service delivery. The home is in the process of developing a structured supervision framework. Team leaders are now receiving formal one to one supervision from the manager. Team leaders would in turn be expected to supervise the care staff. Some care staff spoken to confirmed that the process has started. It was noted that the manager does not receive any formal supervision. It is required that the responsible individual should ensure that arrangements are put in place for the manager to have formal supervision on a regular basis. Information recorded on the pre-inspection questionnaire under section A5 indicated that the fire equipment was serviced on 23 January 2006. The date of the most recent fire drill was 3 May 2006. The environmental health officer visited the home on 31 March 2006. Matters relating to food handling and hygiene were found to be satisfactory. The passenger lift was last serviced on 1 July 2006. The bath hoists were serviced on 14 March 2006. The mobile hoists were serviced on 9 March 2006. Wheelchairs were serviced on 11 January 2006. Checks on the temperatures of hot water outlets are maintained. COSHH sheets are available for all cleaning substances and solutions used in the home. The fire records seen indicated that the fire panel and emergency lights are checked weekly. All fire zones in areas of the building are regularly activated to ensure that they are working satisfactorily. Accidents sustained by residents are recorded in the accident book. The manager analyses all accidents that occur in the home monthly. It was noted that some residents had been referred to the falls clinic and had been issued with hip protectors to prevent any bony injuries. It was noted that in bedroom 18 the bedside lamp lead could pose a trip hazard. The electrical socket was some distance away from the table. In bedroom 25 the lead for the standing electrical fan in the room also posed a trip hazard. Risk assessments must be put in place to ensure that any potential hazards are minimised. DS0000023016.V295425.R01.S.doc Version 5.2 Page 22 DS0000023016.V295425.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 DS0000023016.V295425.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 OP3 Regulation 14(1)(a) Requirement The registered manager must ensure that the home is consistent and assess all residents prior to admission to ensure that individuals’ needs would be fully met. The registered manager must ensure that residents have a care plan that is current and reflects their needs. Care plans must be reviewed monthly. The registered manager must ensure that that staff comply with the British Pharmaceutical guidelines when administering and recording medication. (Previous timescale of 31/01/06 not met) The registered manager must ensure that staff’s competencies in the administration and recording of medication are regularly assessed. (Previous timescale of 31/03/06 not met) The registered manager must DS0000023016.V295425.R01.S.doc Timescale for action 30/09/06 2 OP7 15(1) 31/10/06 3 OP9 13(2) 31/10/06 4 OP9 13(2) 31/10/06 5 OP19 23(2)(b) 31/01/07 Page 25 Version 5.2 6 7 OP19 OP19 23(2)(b) 23(2)(d) 8 OP29 19(1) 9 OP30 18(c)(i) ensure that the seal in the double glazed window in the conservatory is replaced. The registered manager must ensure that the floor tiles in the conservatory are replaced. The registered manager must ensure that ceiling lights in areas of the building are cleaned regularly. The registered manager must ensure that all staff recruited have a completed application form and an up to date photograph on file to confirm proof of identity. The registered manager must ensure that mandatory training for staff is kept updated. The registered manager must ensure that an effective quality assurance system be developed to seek the views of residents and relatives about the service delivery. (Previous timescale of 31/03/06 not met.) The registered manager must submit an improvement plan to the Commission in response to the requirements and recommendations made in this report. The responsible individual must ensure that arrangements are made for the manager to receive formal one to one supervision on a regular basis. The registered manager must ensure that risk assessments are developed in bedrooms 18 and 25 for the electrical leads that pose a trip hazard. 31/01/07 30/09/06 30/09/06 31/10/06 10 OP33 10(1) 31/12/06 11 OP33 24(a) 28/09/06 12 OP36 18(2) 31/10/06 13 OP38 13(4) 30/09/06 DS0000023016.V295425.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations It is recommended that the registered manager should ensure that whenever possible care plans are signed by residents or their representatives and they are audited regularly. It is recommended that the registered manager should ensure that lactulose bottles are wiped after use with a damp cloth. It is recommended that the registered manager should ensure that the filing cabinets on the units that are used to store care plans be kept locked to ensure that data protection and confidentiality are not breached. 3. OP9 3 OP14 DS0000023016.V295425.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. 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