Inspection on 28/11/05 for Rushymead

This inspection was carried out on 28th November 2005.

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 19/07/06

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 Announced Inspection 28th November 2005 09:30 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.V249165.R01.S.doc Version 5.0 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.V249165.R01.S.doc Version 5.0 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 Ms Janet Casselden Care Home 28 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (28) of places Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 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 and 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. The home has extensive gardens that are well maintained. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection of the home, which took place on the 28th November 2005 from 09.30 am to 4.30 pm. The lead inspector was Ms Joan Browne who was accompanied by Mrs Gill Wooldridge (Inspector) The inspection consisted of meeting with residents and staff, examination of care documentation and records. A tour of the communal areas and some bedrooms was carried out. The serving of lunch was observed on one of the units. Residents spoken to were complimentary about the provision of care and made the following comments about their experiences of living in the home: ‘Staff are very kind,’ ‘the food is good’, ‘I am happy living her.’ Feedback was given to the manager, deputy manager and the project manager on the findings of the inspection. What the service does well: What has improved since the last inspection? Bathrooms, corridors and toilets in some units have been redecorated. Some armchairs and curtains in some lounges have been replaced. The floor covering in one particular bedroom has been replaced with wooden floor covering. Some beds have been replaced. One of the en suites has been re-tiled. The domestic team has introduced a more effective cleaning schedule. Swing top bins in the kitchenettes and some bathrooms and toilets have been replaced with the foot pedal type to prevent the spread of cross infection. More permanent staff have been recruited. Opened bottles of sauces stored in the kitchenette refrigerators are now dated and labelled. The medication Nitrazepam is treated as a controlled medication. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 6 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. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 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 Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 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): EVIDENCE: Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 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 Care plans need to be developed and interrelate to ensure that residents’ needs would be fully met. Arrangements were in place to ensure that residents’ health and personal care needs are fully met. However, protocols developed should interrelate with the care plans to ensure needs identified would be fully met. There are still inconsistencies in the administration and recording of medication, which has the potential to put residents at risk. EVIDENCE: The home uses the Standex care planning system. Five care plans that the home’s staff had been working on were examined. It was noted that there was some improvement in the recording and presentation of the care plans in some areas. However, some further work is required to ensure that the standard is fully met. The following was noted: relatives’ telephone numbers were missing from individuals’ personal details and individuals’ long term needs were not reviewed regularly. The key worker section in care plans was not regularly updated. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 10 It was noted that a particular resident was presenting challenging behaviour and shouting at staff and residents. However, a plan of care and an action plan relating to the individual’s behaviour had not been developed. In the daily record for one particular resident it was noted that staff were locking the individual’s bedroom door. This could be perceived as a restriction of the individual’s liberty. There was no detailed information recorded in the care plan, to indicate that the resident’s relative was consulted and was in agreement with the action that the home’s staff were taking. There was also no evidence that the action was being kept under review. It is acknowledged that this practice is not happening. Information recorded in the daily record was not interrelating with the care plan. For example, an entry recorded in the daily record for a particular resident indicated that the individual was depressed. A plan of action relating to the individual’s depression had not been developed. Staff’s described practice was detailed however, this detail was not always reflected in the care plan. There was no change to a particular resident’s care plan, which appeared contrary as described in the previous inspection report. The plan identified that the individual needed full assistance when washing and dressing. However, the information recorded in the action plan was that staff should ‘fill the sink with water and give the individual the flannel to wash himself’. It is acknowledged that there was an addition to the care plan. However, this could be confusing for any new member of staff. The multi-disciplinary sections in care plans relating to physiotherapy, chiropody and nursing input contained good detailed information. However, information recorded in the nutritional sheets needed to be clearer. There were no short-term social care plans developed for individuals. It is acknowledged that some information relating to likes and dislikes were recorded on an activity sheet and on long-term care plans. There was no evidence that night care plans were being evaluated. Information recorded in the daily evaluation sheet was not always followed through. For example, in one particular resident’s daily record it was noted that the individual’s urine was offensive. Fluids were offered during the night however, there was no follow up report recorded in the day report. In some care plans examined residents’ weights were checked and recorded monthly. However, it was noted in one particular resident’s weight record that on admission the individual’s weight was recorded in stones. However, subsequent monthly weights were recorded in kilograms. Staff need to be consistent when recording individuals’ weights to avoid any confusion over weight gain or lost. The language used in some care plans could be seen as derogatory. The following information was recorded in a particular resident’s care plan: ‘Needs lots of patience at times very strong willed.’ It is recommended that whenever possible residents and relatives sign the care plans to confirm their involvement. An audit system of care plans must be developed to ensure that plans are working documents. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 11 Arrangements were in place for meeting the health and personal care needs of residents. However, a protocol needs to be developed for the resident with an indwelling catheter, this should inter-relate with the individual’s care plan to ensure that the identified need would be fully met. The medication administration record (MAR) sheets were examined and showed that some concerning inconsistencies in staff recording practice persists. These included staff not using codes to denote if medication or creams were administered as prescribed. Some entries recorded were scribbled over and handwritten entries on MAR sheets were not dated and signed by two staff members. When antibiotic treatment was completed not all staff were dating and signing the entry. There was no written evidence to substantiate that MAR sheets were audited regularly and that staff’s competencies were regularly assessed. These issues were subject to a requirement at the two previous inspections. The registered manager must explain to the Commission why this requirement has not been met and what actions the manager will put in place to ensure that the standard is met. Non-compliance with requirements may result in the Commission consulting its legal department with a view to consider enforcement. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 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 Arrangements are in place to ensure that residents’ social religious and recreational interests are catered for. Visitors are welcome to visit at anytime this ensures that residents maintain contact with their families and friends. Satisfactory arrangements were in place to support residents to exercise choice and control over their lives. An appropriate range and variety of meals were on offer to residents. EVIDENCE: Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 13 Residents confirmed that the routines of daily living and activities were flexible and varied to suit their life styles. The home has an activity organiser who provides activities three days a week. It was noted that an outing to the local theatre had been booked along with other festive activities. Residents are able to have visitors anytime within reason and visitors are made to feel welcome by staff. Residents spoken to confirm that they maintain links in the community. The local Brownies and a lay preacher visit the home regularly. Two residents look after their own financial affairs. The home informs residents that they are able to bring in personal belongings if they wish to. Some bedrooms were personalised with items of furniture pictures and mementoes. There were no residents using the services of an advocate at the time of the inspection. The home’s manager was advised to explore if a local advocate would be willing to visit the home regularly to represent residents. Lunch was observed on one unit. Tables were appropriately set with tablecloths, cutlery and condiments. A choice of fruit juices was on offer. Choices on offer in the main course were beef casserole, haddock in parsley sauce, tuna salad, potatoes, carrots and peas. Dessert was bread and butter pudding and custard or cheese and biscuits. Residents spoken to were complimentary about the lunch and said that ‘the food is always good’. Some good interaction amongst residents and staff was noted during lunch. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 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 Complaints are appropriately actioned this ensures that residents’ and relatives’ views are listened to. Staff spoken to were aware of how abuse may manifest itself. However, senior managers need to familiarise themselves with the revised Buckinghamshire County Council policy and incorporate it into the organisation’s policy. These measures should ensure that residents are protected from abuse. EVIDENCE: The home’s complaints folder was accessible on the day of the inspection. The home has not received any verbal or written complaints since the last inspection neither has the Commission. All staff had undertaken in-house training in adult protection and abuse awareness. Staff spoken to were aware of the different types of abuse and how they could be manifested. Senior managers were not aware of the revised Buckinghamshire County Council adult protection policy. Advice was given to the manager on how to obtain a copy of the policy along with names of personnel who are directly linked with adult protection issues and training at the local Social Services office. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 15 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, 21 22 & 24 The physical environment was well maintained, ensuring residents lived in safe, attractive and comfortable surroundings that were suitably equipped to meet their needs. EVIDENCE: Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 16 Residents live in a safe, pleasant, comfortable and homely accommodation. Several toilets, bathrooms, corridors and lounges were recently decorated and curtains and furniture in some areas replaced. There is an adequate amount of communal space on each unit. Bathing and toilet facilities are sufficient in size, number, location and design. Residents have specialist equipment they require to maximise their independence for example, the home has a passenger lift, several hoists and wheelchairs. Bedrooms were personalised with residents’ own furniture, family photographs and mementoes. Call bells, which were easily accessible, were fitted in individuals’ bedrooms. On the day of the inspection the home was clean, hygienic and free from offensive odours. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 17 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 An appropriate number of staff were on duty, which should ensure they meet the needs of residents. 50 of the staff team have achieved NVQ 2 qualification, which ensures that residents are in safe hands at all, times. There were some inconsistencies in the vetting of staff working in the home. This has the potential to put residents at risk. The home’s training programme in dementia and challenging behaviour need to be developed to ensure that staff are trained and competent to meet residents’ needs fully. EVIDENCE: Overall the home was adequately covered on the day of the inspection. There were five care staff allocated to work on three units. This number included the team leader who was leading the shift. In addition there were two senior carers who were recently recruited from China and were supernumerary to the rota as they were still on induction. The staffing number at nights was increased to three night staff. The manager, deputy manager and project manager were also supernumerary to the rota. There was also an adequate number of housekeeping staff available. The general housekeeping staff were no longer expected to help out in the general kitchen; this has allowed them to develop a more effective cleaning schedule. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 18 Senior managers commented that morale amongst the staff team especially the senior team had improved. Managers had made a concerted effort to make staff aware of any new changes that were being introduced and to seek their views. It was noted that 50 of care staff had achieved National Vocational Qualification (NVQ) in direct care in level 2 and 3. Senior managers stated that all staff who have achieved NVQ 2 would be given the opportunity to undertake NVQ 3 if they wished to. Three staff members’ files were examined this included the two staff members who were recruited from overseas. It was noted that there were no completed application forms for the two staff members who were recruited from overseas. Copies of references were available but there were no footnotes recorded to confirm that originals were seen and they were authentic. There was evidence that police clearances were obtained for the two personnel in China. However, ‘POVA first’ checks were not on file (as required for staff appointed after 24 July 2004 pending the Criminal Record Bureau (CRB) disclosure). A ‘POVA first’ check and CRB clearance was in place for the third staff member. However, the status of references was unclear i.e. no information on the status of the referee, or, where employer, the authority of the person to provide a reference. The manager was advised to apply for ‘POVA first’ checks immediately for the two overseas personnel. In the interim a risk assessment must be developed to ensure that the two staff members do not provide personal care to residents and that they are supervised by an experienced member of staff at all times. It is required that weaknesses in the home’s recruitment procedure be addressed. There was evidence that some staff had undertaken mandatory training. However, it was noted that moving and handling training is not available to all staff at the beginning of their induction. The manager explained that this was because an outside trainer facilitates the training. Staff members are advised not allowed to use the hoist and to assist in moving and handling residents. The manager is advised to review this practice. Dementia and challenging behaviour training has not been included in the home’s training programme. The manager stated that two senior staff would be undertaking dementia mapping training next year. It is required that dementia and challenging behaviour training is included in the home’s training programme to ensure that staff are trained and competent to do their jobs. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 The management team is working towards achieving the required level of formal professional qualification. This would ensure that persons who are fit to discharge their responsibilities manage the home. The home does not have any quality assurance and quality monitoring systems in place to ensure that residents are given the opportunity to comment on the service provision. A supervision framework needs to be developed to ensure that staff are appropriately supervised to meet residents’ needs. Shortfalls in records pertaining to health and safety may put residents at risk. EVIDENCE: Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 20 The home’s manager is experienced, of good character and able to discharge her responsibilities as manager of the home. The deputy manager and project manager have both enrolled on formal professional qualification for NVQ 4 or equivalent to support her. The manager stated that residents’ needs are paramount and staff are aware that the home is run in the interest of the residents. She also stated that staff are encouraged to be innovative and creative about the development of the service delivery. She explained that staff were involved in the development of the new menu request forms. However, strategies need to be developed further to enable, residents, relatives and staff to affect the way in which the service is delivered. There are no quality assurance and quality monitoring systems in place to seek the views of residents and relatives. The home does not have an annual development plan in place. It is required that the manager develops an audit system to obtain residents’ and relatives’ views. Monthly internal auditing of care plans, medication administration and record sheets and health and safety records should also take place. It was noted that comment cards from residents or relatives were not received. However, one comment card was received from a health care professional who was satisfied with the provision of care. The home does not have a structured supervision framework in place. It is required that the manager develops a supervision framework to ensure that all staff are adequately supervised. There was evidence that the fire panel was checked weekly. However, the emergency lights were not being checked monthly. This was a requirement at the previous inspection and has not been complied with. The manager must write to the Commission to explain why the requirement has not been met. Non-compliance with requirements may result in the Commission consulting its legal department with a view to consider enforcement. There was evidence that wheelchairs were checked monthly. Hot water temperature records examined indicated that monthly checks are carried out and temperatures were within satisfactory range. The hot and cold water system within the building was recently replaced and a copy of a letter from the home’s mechanical services contractors was made available confirming that no trace of asbestos insulation had been found. Service records indicated that the passenger lift was serviced on the 9 September 2005 and the mobile hoist on 23 September 2005. It was noted that one particular resident’s bedroom door on the first floor was kept open with a door wedge and posed a safety risk. The manager must ensure that an appropriate door holding device or dor-gard is fitted to the individual’s door after consultation with the fire officer. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 21 It was recorded in the daily log for a particular resident that the individual had fallen out of bed during the night. This resulted in the individual sustaining a head injury. There was no detailed information recorded by staff as to what action they had taken and how they were monitoring the individual’s condition. It is recommended that the accident and incident procedure be improved and all staff are made aware of their responsibility and how to respond appropriately to emergency incidents. Staff are reminded of their responsibility to report any serious injury to a resident to the Commission. Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 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 3 X 3 3 X 3 X X STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 1 x 2 Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 23 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 detailed action plans are recorded in individual’s care plans. Information, which could be perceived, as restriction of liberty must be fully documented. An audit system of care plans must be developed to ensure that plans are working documents. (Previous timescale of 30/06/05 not met.) The manager must write to the Commission within two weeks of receiving this report to explain why this requirement has not been met. The registered manager must ensure that that staff record medication in accordance with the British Pharmaceutical Guidelines. (Previous timescale of 06/01/05 not met.) The manager must write to the Commission within two weeks of receiving this report to explain why this requirement DS0000023016.V249165.R01.S.doc Timescale for action 31/01/06 2 OP9 13(2) 31/01/06 Rushymead Version 5.0 Page 24 has not been met. 3 OP9 13(2) The registered manager must ensure that staff’s competencies in the administration and recording of medication are regularly assessed. The registered manager must ensure that POVA first checks are carried out immediately for the two overseas staff members. In the interim a risk assessment must be developed to ensure that the two staff members do not provide personal care to residents and an experienced staff member supervises them. The registered manager must ensure that weaknesses in the home’s recruitment procedure be addressed. The registered manager must ensure that dementia and challenging behaviour training are included in the home’s training programme. The registered manager must ensure that an effective audit system be developed to seek the views of residents and relatives about the service delivery The registered manager must ensure that a structured supervision framework be developed. The registered manager must ensure that the emergency lighting is checked monthly. The registered manager must ensure that residents’ bedroom doors are not wedged open. Those residents who wish to keep their bedroom doors open must have the appropriate door holding devices or dor-gards fitted. 31/03/06 4 OP29 19(1) 28/11/05 5 OP29 19(1) 31/01/06 6 OP30 18(c)(i) 31/03/06 7 OP33 10(1) 31/03/06 8 OP36 18(2) 31/03/06 9 10 OP38 OP38 13(4) 13(4) 31/01/06 28/11/05 Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP8 Good Practice Recommendations It is recommended that the registered manager should ensure that whenever possible care plans are signed by residents or their representatives. It is recommended that the registered manager should ensure that a protocol be developed for the resident with an indwelling catheter and it interrelates with the individual’s care plan. It is recommended that the registered manager should ensure that regular auditing of MAR sheets is carried out. It is recommended that senior manager should be familiar with the Bucks County Council adult protection policy and incorporate it into the home’s policy It is recommended that the registered manager should ensure that the home’s accident and incident procedure be improved. All staff should be made aware of their responsibilities and how to respond to appropriately to emergency situations. 3 4 5 OP9 OP18 OP38 Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Rushymead DS0000023016.V249165.R01.S.doc Version 5.0 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!