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Inspection on 15/07/08 for Rydal House Nursing Home

Also see our care home review for Rydal House Nursing Home for more information

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Some residents had a very active lifestyle where they were supported by families and friends to go out from the home and access a range of community services. The numbers of staff on duty for the majority of the time appears to have improved since the last visit, there are significant deficits however in the recruitment, induction, training and supervision of staff.

What has improved since the last inspection?

A new care plan format had been introduced since our last visit and whilst generally the paperwork was improved this was not always fully completed or utilised fully.

CARE HOMES FOR OLDER PEOPLE Rydal House Nursing Home 21 Somersall Lane Chesterfield Derbyshire S40 3LA Lead Inspector Bridgette Hill Unannounced Inspection 15th July 2008 09:10 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 Rydal House Nursing Home DS0000002073.V368401.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. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rydal House Nursing Home Address 21 Somersall Lane Chesterfield Derbyshire S40 3LA 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) 01246 569511 hitch_d@yahoo.com Mr D Chand Dr. Anjuman Diwan Chand Mr Charles David Hitch Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th November 2007 Brief Description of the Service: Rydal House is situated on the western side of Chesterfield within a pleasant residential area, close to local amenities and within easy access of a main bus route. The home is a converted building, with an extension, set in its own grounds. It has separate lounges and dining rooms, on the ground floor. A conservatory has been added. The home has provision for nursing and personal care, and is registered to provide care for a maximum of 31 residents. Fees range from £333.85 - £498.30 extra charges are made for chiropody, hairdressing, newspapers and toiletries. This information was gathered at the inspection of the home. The latest inspection report and a Statement of Purpose was available in the office for service users or their representatives to see. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 Star. This means the people who use this service experience Poor quality outcomes. The inspection visit was unannounced and took place over 2 days totaling 8 and ½ hours. Additionally, time was spent in preparation for the visit, looking at previous reports and other relevant documents and preparing a plan for the inspection. The Annual Quality Assurance Assessment that the home completes was returned to us before we visited and considered as part of this inspection. Surveys were sent out prior to the visit to residents, staff and relatives and where these were returned to us the information received has been included in this report. As part of the planning of the visit the Annual Quality Assurance Assessment and the survey information was considered, as was the previous inspection report. There were 23 people living at the home on the day of the inspection. 5 residents, 1 relative and 4 staff were spoken with during the visit. As part of the inspection a sample of service users care files and a range of documents were examined. The communal areas were viewed along with some bathrooms and bedrooms. The registered Manager David Hitch was available on the second day of the visit. What the service does well: What has improved since the last inspection? A new care plan format had been introduced since our last visit and whilst generally the paperwork was improved this was not always fully completed or utilised fully. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Rydal House Nursing Home DS0000002073.V368401.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 Rydal House Nursing Home DS0000002073.V368401.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are arrangements in place prior to admission to ensure that people are assessed and the home has information on residents assessed needs however it has not always been assured that residents needs are within the registration category the home is registered and therefore needs may be unmet. EVIDENCE: We looked at the systems in place for new residents choosing the home as a place to live. The Annual Quality Assurance Assessment completed by the Manager told us that residents are initially admitted on a 12 week trial basis and prospective residents are invited to visit the home and have a meal or overnight stay before moving in. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 9 One resident told us they were given the opportunity to visit the home before they moved in and were happy with the choice they had made. We were told that generally residents did have terms and conditions contracts in place, only one survey received said that they were not sure if they had received one. The care files we looked at contained the completed assessments and copies of the care management assessments. Residents told us that they chose the home for a range of reasons; some being as it was near to family for others they had some knowledge of the through family or lived locally to it. The last inspection report was available in the office at the home but wasn’t available publicly nor was any attention drawn to where to find it on the notice board of the home. The Service User Guide had also been updated and copies of these were seen in the staff office. Discussions were held during the visit regarding the admission of one resident who did not fit within the registration category of the home. A minor variation had initially been submitted to Commission for Social Care Inspection and a letter returned informing the home that a major variation was required; to date this had not been submitted. Discussions with the Commission for Social Care Inspection registration team and the Manager have occurred after the visit and assurances given to us that an application will be submitted. The home does not offer intermediate care as defined by National Minimum Standard 6 Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst improved the care plan format was not fully being used to ensure that the care residents required was fully recorded and therefore staff may be unaware of how to deliver care to residents. EVIDENCE: We looked at a sample of two care plans to examine if they were descriptive of the residents care needs. Since the last visit the Annual Quality Assurance Assessment told us a new care planning format had been introduced by the new Manager. The care plan format in place was more extensive than the one previously used however on the ones we looked there some very significant deficits. Some risk assessments had not been competed in particularly the Moving and handling one where it was clear from assessments the residents did need assistance. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 11 Some staff spoken with said they had looked at the care plans but others had not. Some poor record keeping was evident with some forms having dates and signatures missing so it was not possible to assess the validity of them. Some care plans recorded that residents had varying ability each day and gave the scope of these abilities. The same care plan also had key information missing which did not vary such as the type of continence aid to be used. Records were written by staff each shift to give an account of the resident each day. Were special equipment was assessed as being needed these were observed as being in use in the residents bedrooms. Where residents had received GP visits or visits from other healthcare professionals such as opticians and chiropodist’s records of these were kept. Information on a notice board told residents when to expect the chiropodist to visit. The surveys and discussions with residents told us that sometimes relatives were involved in helping residents to healthcare appointments. We looked at the medication administration records and generally it was found that residents were receiving all their medication on a regular basis. Records were kept of what medications were received into the home and a returns book documented the disposal of medicines. Some medicines that had been refused were not found to be included in this record so a full audit of medicines was not possible. An up to date drug reference book was available to staff. Since the last visit a new drugs fridge was in place and the temperatures of this was recorded each day and medicines were being stored at correct temperatures. Whilst medication administration records tended to be printed by the pharmacist some for new admissions and additions part way through the month cycle were handwritten. These were often but not always doubly signed and checked by a second staff member to verify they were correctly recorded before administration. Some homely remedies directives which were signed by GP’s were available but clear instructions and protocols for when homely remedies should be considered, given and possible contra indications were not in place. Information from surveys told us that staff were friendly and helpful. Another comment told us that it was considered that more care could be taken with the laundry and to ensure residents were dressed properly and kept smart to ensure resident’s dignity was maintained. Where residents were in their rooms we observed staff knocking before they entered. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 12 We discussed with staff their knowledge of residents needs such as special diets. Some staff were unable to give us accurate information about the residents assessed needs. One relative told us the home kept losing items such as glasses and slippers. Residents told us staff were ‘nice and helpful’ and that the home was a ‘friendly’ one. One resident told us they preferred personal care from female staff and this was respected. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle and social fulfilment is largely met by families and where residents can follow their own interests. For more dependent residents there is little social stimulation offered at the home to meet resident’s needs. EVIDENCE: The Annual Quality Assurance Assessment completed by the Manager acknowledged that a defined activities programme was one area that could be improved on and on discussion during the visit it was apparent that few activities are offered to residents. The Annual Quality Assurance Assessment told us there are open visiting arrangements in place. The activities offered appear to be defined to the hairdresser visiting. One staff survey told us however that the hairdresser tends to do the same residents hair each visit. Staff during the visit told us that some board games and dominoes were available and that a local Minister from the church visited occasionally. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 14 The responses we received from residents told us that activities were ‘sometimes’ or ‘never’ held. This was reflected in what residents told us about the home. Some residents were observed reading or doing puzzle books and some residents used their bedrooms to watch television of their choice. One resident told us they read the books that were available at the home. Staff said that occasionally they took residents out to a local shop. The surveys we received from residents told us that people would like more activities offered to them so that they ‘are not just sat around’. A four weekly menu was available on a board outside the kitchen and records told us that this was reflective of what was served. The board was small to read and would be difficult for most people to understand what was due to be served as it was not clear which week the menu was on. The meal was served to residents in differing sized portions according to appetite. Staff sat by residents and wore aprons to help them with their meal. Residents told us they get a choice of cooked breakfast with different foods offered each day. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were not clear procedures in place for ensuring a consistent approach to concerns and allegations is being taken. Not all staff had sufficient training to ensure they had knowledge of abuse and how to deal with this should they be concerned about residents in the home. EVIDENCE: A complaints procedure was on display in the entrance hall for residents and visitors to view which gave timescales and the address of the Commission for Social Care Inspection. In the policy file a further 3 different complaints procedures were in place, all with different registering authority addresses. The Annual Quality Assurance Assessment told us that there had not been any complaints or Safeguarding Adults referrals made in the past twelve months and the Commission had received no complaints. At the time of the visit there was one Safeguarding Adults allegation that was received by the Commission for Social Care Inspection and referred to Social Services Safeguarding Adults procedures which was in the process of being investigated. We asked to look at the complaints log at the home but this could not be located. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 16 The residents we talked to say they would to staff if they needed to or had any worries. On the whole they were able to give the names of staff they talk to. The surveys we received did not have any comments on them but it was generally ticked that people knew how to make a complaint if they needed to. One relative told us they had seen the complaints procedure on the notice board. Staff we talked to had different levels of knowledge and training regarding Safeguarding Adults. Some staff had received training and knew about the procedures in place. For staff typically more recently employed there had not been any training received and there was poor knowledge of procedures such as the whistle blowing procedure. One staff member told us they thought that Safeguarding Adults was about ‘how you treated people’. All staff however said they would talk to the Manager or Nurse in Charge if they saw anything that they were concerned about. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was found to be generally well maintained and provided a comfortable home for residents to live in. EVIDENCE: The home is an extended building which was previously a domestic property. Since the last inspection there has been some rearranging of the lounges and dining room. One larger dining room was now used and this was well presented with tablecloths, cruets and sugar bowls on tables. A range of lounges and a conservatory are available to residents to sit in. Each resident appeared to have their own chair where they preferred to sit. One of Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 18 the lounges had the television on where others were quieter areas. Residents we spoke to said they each had their own preferred area. The home appeared to be generally well kept decoratively throughout. The training matrix given to us indicated that some fire safety training had been completed but some updates were now due and that a few staff had no recorded fire safety training date recorded. The arrangements for checking and ensuring the fire alarm and other fire precautions were in place appeared to be satisfactory. Residents told us they liked their bedrooms and had some of their own possessions in them. One resident told us their room was large like a bed-sit and they had their own safe and fridge in it. The rooms in the home were of varying size and shape. No rooms had en suite facilities but all had a washbasin. The Annual Quality Assurance Assessment told us there had been some redecoration of bedrooms since our last visit and some was underway during the visit. The laundry door was not locked and had some chemical detergents openly stored in the room. The home had one washer and one dryer. Residents told us they were generally happy with the laundry service. The surveys we received told us that generally the home was fresh and clean. Staff told us they had access to gloves and aprons when they needed and were seen with them in their pocket ready to use, as they needed to. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Poor training, recruitment and induction procedures mean checks are not in place before staff work with vulnerable residents which may mean staff are not suitable and have insufficient knowledge and training to meet residents needs. EVIDENCE: The occupancy at the home on the day of the visit was 23 residents, 9 residents out of these required nursing care. Of the surveys we received from staff most said they considered there was enough staff on duty to care for residents needs. Some staff during the visit told us however that there were times when numbers of staff fell due to sickness/holidays. The typical levels for staffing were one nurse for all shifts, plus 3 carers for each day shift and two carers at night. The Annual Quality Assurance Assessment completed by the manager told us that all staff received an induction. A skill based induction pack was available although discussions with the Manager confirmed that this was not being issued to new staff or worked through with them to ensure they had the necessary knowledge and skills to meet peoples needs. Staff we talked to told us they did receive some induction which was a checklist type induction and Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 20 spent some time shadowing more experienced staff when they began work at the home. When the skill based induction pack was discussed with them they said they had never seen this or been offered it to work through. The surveys we received from staff were variable with some saying they had regular support and sufficient information about residents where others said that only sometimes did they get support and information. It was again variable but most staff surveyed thought there was enough staff to meet people’s needs. Suggestions for improvements were the introduction of a kitchen assistant and activities coordinator. There were few comments record but one staff thought residents were well cared for. Some staff had written ‘no comment’ in when asked what the home does well. We looked at how the recruitment process was implemented and if this safeguarded the residents at the home. The three files we looked at were for a range of staff recent and those who had been in post for a few years. Some of the files we looked at did not have independently sought references. A testimonial, which was not recent, had been accepted and a number of telephone references had been accepted. Criminal records Bureau checks were in place in two files and one staff member was working supervised with a Pova First check having been obtained. Application forms and proofs of identity were included. We discussed training with the Manager and looked a training matrix that was supplied to us. This indicated that during the past six months there had not been any training taking place. The Manager said that this was purposeful as they were not sure that the previous training had been beneficial to the service residents received. Moving and handling training was out of date and for newer staff no formal Moving and handling training had been completed at all. Staff told us they had been shown by other staff, (not moving and handling trainers) how to help residents to move. We observed untrained staff assisting residents to move during our visit. For some staff this was their first job providing care and no formal training or skill-based induction had been given. The Manager told us that they were nearing the completion of a Moving and handling trainers course and was planning to deliver this training to staff on completion of this. No training had been completed in mental capacity or the impact this would have on the consideration of residents care. There were 15 care staff employed at the home of these there were 8 who had achieved a National Vocational Qualification to enable them to care for residents. This meets the National Minimum Standard of 50 of staff who are suitably qualified. Rydal House Nursing Home DS0000002073.V368401.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is insufficient management of the home to ensure that staffing and health and safety requirements are met which may impact adversely on the care residents receive. Residents are not being consulted about their views of the home. EVIDENCE: Since the last inspection a new registered manager is in post who had already achieved a managerial qualification and had experience of running other care homes. The assessment of the staffing at the home has identified a number of areas where this is not being managed sufficiently this includes poor recruitment, Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 22 induction and training for staff which will directly impact on the care residents receive. A range of surveys was available on the notice board for residents, relatives or visiting professionals to complete. We looked at completed surveys and found that no surveys had been given out or returned since April 2007. Therefore there was insufficient work being completed to evidence that service users views were being sought and acted upon. The responses given in the surveys we saw were very mixed, some were quite positive but other comments include ‘average food’, ‘few activities’ and that the cleanliness of the home could be improved. Some comments regarding staff being rude were ticked on a number of surveys but no comments to give examples of this. The Provider was visiting the home on at least a monthly basis and was recording these visits on a Regulation 26 form. These had brief details recorded but did include some discussions with residents. The Manager told us that no staff or residents meetings had been held. Some monies are stored safely for residents and records are kept which contained space for two signatures to verify transactions although not all transactions had been signed by two staff. A sample check of balances indicated that all of the resident’s money was stored separately and the amount of money available matched the records held. Whilst the Manager had been on a recent holiday other staff told us that no residents had been able to access their monies Staff at the home told us that they were not receiving any formal supervision from the Manager. Staff told us they had completed the 3 month trial period and been accepted onto permanent contracts without a formal appraisal of their work, skills and knowledge. Limited supervision records for long serving staff were in files but no recent supervisions were evident since the current manager had been in post. Since the last visit the care records for residents had been moved and were now kept on open shelving in an office which staff told us was not locked when in use. We observed the office door being left wide open when no staff were in the vicinity placing residents confidentiality at risk. The Annual Quality Assurance Assessment gave us details of the service checks that had completed to ensure the building was safe. Whilst most were in date the gas appliances had not been serviced since 2006. We could also not find any records to evidence there had been testing of portable appliances since 2002. Some records were taken of water temperatures to ensure the risk of scalding was being managed. Some of the temperatures were lower than recommended and it was recorded that a plumber had been informed. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 23 There were aspects of the Environmental Health Officers last report which remained outstanding this included the ventilation hood in the kitchen not working. Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 1 2 2 Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 25 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 Requirement Residents must not be admitted to the home unless their needs are within the categories the home is registered to accept. Where there are residents who fall outside of the homes categories of registration an application must be submitted to the Commission for Social Care Inspection to ensure the home is registered and able to meet the needs of the residents Personalised care plans must be in for each service user which informs staff of service users needs are to be met This requirement has been made at a previous visits and was considered partially met at his visit 3 OP7 13(5) Where service users require assistance with Moving and handling there must be risk assessments in place for this A record must be kept of all medications received into the DS0000002073.V368401.R01.S.doc Timescale for action 30/08/08 2 OP7 14 30/08/08 30/08/08 4 OP9 13 (2), 17 (1) (a) 30/08/08 Rydal House Nursing Home Version 5.2 Page 26 5 OP12 16 (2) (m) home and any returns made to pharmacy to ensure an audit trail is possible and a record of all the treatment service users have received is kept The registered person must ensure that activities and therapy are available to meet the needs of the service user’s social, cultural, religious and recreational interests. 30/09/08 6 OP18 13(6) 7 OP18 18 Previous timescales 31/05/07 & 31/12/07 There must a Safeguarding 30/08/08 Adults procedure in place which is clear in the actions to be taken following an allegation and refers to locally agreed procedures The registered person must 30/09/08 ensure that all staff receive training on Safeguarding Adults and are conversant with the Safeguarding Adults procedures and whistle blowing policy to ensure residents are protected The provider must ensure staff do not commence employment until all required checks and documentation are satisfactorily in place as detailed in Regulation 19 and Schedule 2 Staff must undertake a structured skill based induction to ensure they have the skills to meet service users needs The provider must ensure that staff receive training in moving and handling by persons who qualified to train others The registered person must ensure that a quality assurance system with a systematic cycle is in place and being operated. All staff must have regular DS0000002073.V368401.R01.S.doc 8 OP29 19 Schedule 2 30/08/08 9 OP30 18 30/08/08 10 OP30 18 30/09/08 11 OP33 24 30/10/08 12 OP36 18 30/09/08 Version 5.2 Page 27 Rydal House Nursing Home 13 OP37 17(1)(b) 14 OP38 13,23 15 OP38 23(2)(c) individual supervision and an annual appraisal. Service users personal records must be held securely at all times to ensure service users confidentiality is protected The Provider must ensure the gas installations at the home are serviced by suitably trained persons and are safe to use Portable electrical appliances must be checked by a person who is competently trained to ensure they are safe to use All requirements listed in the Environmental Health Officers last report must be actioned to ensure the kitchen provides a safe environment for food preparation 30/08/08 30/08/08 30/08/08 16 OP38 23(5) 30/09/08 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 OP15 OP35 Good Practice Recommendations Residents should have access to a clearly written menu which tells then what is being served each day Residents must be able to access the money which is securely held at the home on their behalf Rydal House Nursing Home DS0000002073.V368401.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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