Inspection on 27/07/06 for Salroyd Villa

This inspection was carried out on 27th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Salroyd Villa 25/07/07

Salroyd Villa 02/02/06

Salroyd Villa 27/09/05

Salroyd Villa 26/01/05

Salroyd Villa 09/09/04

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Larchfield Manor

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

CARE HOMES FOR OLDER PEOPLE Salroyd Villa 21 - 23 Salroyd Road Low Moor Bradford West Yorkshrie BD12 0JN Lead Inspector Mary Bentley Key Unannounced Inspection 27th July 2006 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 Salroyd Villa DS0000001287.V306884.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. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salroyd Villa Address 21 - 23 Salroyd Road Low Moor Bradford West Yorkshrie BD12 0JN 01274 603887 01274 411294 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) Mrs Kathleen Ellwood Mr Ian Patrick Ellwood Mrs Kathleen Ellwood Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (11), Physical disability over 65 years of age (1) Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd February 2006 Brief Description of the Service: Salroyd Villa is situated in a residential area just off the main Cleckheaton Road at Low Moor. Car parking is permitted on the road in front of the property. The home is close to local bus routes. There is disabled access to the home at the front of the building. There are gardens and a patio area to the front of the property that residents can use. The home has been converted from two semi-detached buildings and is registered as a care home providing personal care for sixteen older people. Accommodation is provided on the ground and first floor and there is a stair lift linking both floors. There are two bedrooms and a toilet on the first floor that are not accessed by the stair lift. There are fourteen single bedrooms, one of which has en suite facilities, and one double room. The home has two communal bathrooms and four toilets. There are two communal rooms on the ground floor, one is a large lounge/dining area, and the smaller room is used as a dining room and as a quiet area for visitors. Weekly fees range from £328.14 to £364.75. Additional services such as hairdressing, aromatherapy, and newspapers are not included in the fees. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was done in February 2006 and there have not been any additional visits to the home since then. The purpose of this inspection was to inspect all the key standards, (the key standards are identified in the main body of the report), to assess how the needs of people living in the home are being met. The methods used in this inspection included looking at care records and other paperwork such as staff and maintenance records, talking to residents, staff and management, observing care practices in the home and looking at some parts of the home. The home completed a pre-inspection questionnaire and the information provided was used as part of the inspection. The inspection was unannounced; it was carried out on 27 July 2006 by one inspector between the hours of 9.30am and 5.30pm. Feedback was given to the manager and deputy manager at the end of the visit. Comment cards were sent to some relatives before the inspection and comment cards for residents and relatives were left at the home. These provide people with an opportunity to share their views of the service with the CSCI. Information obtained in this way is discussed with the home without identifying who has provided it. One resident completed a comment card and overall was satisfied with the service. No comment cards have been received from relatives. Comment cards were also sent to a number of GP practices and District Nursing teams. Three were returned and showed they were happy with the overall service, one GP said that there was not always a senior member of staff available to deal with them. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Most of the requirements from the last inspection have been dealt with. The home has continued to make improvements to the environment, one bedroom and the first floor corridor have been redecorated, and new bedding has been provided. A new staff rota has been drawn up so that there will be three staff on duty during the day, (until 4.00pm), this will give staff more time to spend with residents and some extra hours have also been allocated to activities. The deputy manager will also have some dedicated “office” hours, which will help her to make sure that the required management systems are in place. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 7 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. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 5 Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. A detailed assessment of needs is done before new residents are admitted to the home. Residents and/or their representatives are given the opportunity to visit the home before making a decision about admission and the first four weeks following admission are designated a trial period. EVIDENCE: The records for two residents showed that detailed pre-admission assessments had been done before they were admitted to the home. One resident said they had been given enough information before they moved in. The first four weeks are a trial period for all new residents; at the end of this time a review takes place to decide if the home is suitable to meet the residents needs. The records showed that residents are involved in these reviews. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 10 The deputy manager said that when residents have been in hospital for an extended period of time she does an assessment before they are discharged to make sure that the home can still meet their needs. Staff said they get information about new residents either from the deputy manager or from the pre-admission assessment. The needs identified during the pre-admission assessment are used to develop the care plans. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents’ personal and health care needs are met in a way that respects their privacy and dignity. Some improvements are needed to the systems for recording medicines to reduce the likelihood of residents being placed at risk. EVIDENCE: The care records of two residents were looked at in detail and the records of another resident were looked at briefly. All residents care records are now held in one file, this makes it easier for staff and residents to have access to them. A self care assessment form has been introduced, this helps staff to focus on the skills and abilities that residents still have and can be used to help residents keep as much independence as possible. The care plans address how personal, health, and social care needs will be met, and some are more detailed than others. However now that the self-care assessments have been Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 12 implemented the deputy manager is planning to develop the care plans to take account of this information. The care plans included information on how spiritual and cultural needs would be addressed. There are risk assessments in place for falls, nutrition, and the risk of developing pressure sores. The home does not provide nursing care and uses these risk assessments to identify when to make referrals to the District Nurses. The deputy manager has introduced a system for monitoring falls. There is one resident with a pressure sore; this is being treated by the District Nurses. They have arranged for a hospital bed and a pressure relief mattress to be provided and have given guidance to staff on how often the resident should be helped to change position. The records show that the resident is helped to move and have a drink at least every two hours. Staff are commended for the level of care and comfort they are providing to this resident and for their attention to detail in completing the care charts. There are bed rails in use for one resident, in addition to the risk assessment done by the District Nurses the home has carried out its own risk assessment. Weights are recorded monthly and if any weight loss is recorded it is dealt with appropriately for example by involving GPs. One new resident lost some weight in the first few weeks after admission, the home dealt with this and she has now regained weight. Residents have access to other health and social care professionals as needed. Health care professionals said they are able to see residents in private when they visit the home. Two senior members of staff recently attended training on palliative care; all staff are scheduled to attend this training. The deputy manager is aware that more information needs to be obtained about residents’ wishes for end of life care. Medicines are checked when they are delivered to the home but this is not recorded. The home has one resident receiving a controlled drug, the home does not have a controlled drugs register as recommended by the Royal Pharmaceutical Society Guidelines. The medicine administration charts were up to date and accurate. All senior staff have done training on the safe management of medicines. Residents said they felt well cared for and GPs and District Nurses said they are satisfied with the level of care provided by the home. Salroyd Villa DS0000001287.V306884.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 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 home. The home has a relaxed and informal atmosphere that promotes flexibility in daily routines and encourages residents to exercise choice and control over their lives. EVIDENCE: The home has a very relaxed atmosphere and daily routines are flexible. Residents can choose where to spend their time and some choose to spend most of their time in their own rooms, this includes having their meals in their rooms. Staff said residents get up when they are ready and go to bed when they want. The inspection was carried out during the heat wave, staff said the exceptionally hot weather had been making some residents very tired and they had wanted to go to bed earlier than usual. Staff have a good understanding of how to help people make choices for example if someone cannot see, they would help them to choose what to wear by describing different colour outfits or by encouraging them to feel the texture of the fabric. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 14 A number of residents have some degree of confusion and could not give an account of their experience of living in the home, however observing practices throughout the day it was clear that they feel comfortable and safe in their environment. For example residents are allowed to wander around the home and staff only intervene when it is necessary for their safety or the well being of other residents. Staff are genuinely kind and caring and this comes across in the way they provide care. For example when one resident became distressed and agitated staff helped her to phone her family and then spent time with her gently diverting her attention to the subject of what to cook for lunch. The home offers a range of in house activities and is working towards providing more opportunities for people to engage in activities outside of the home, for example by taking people to the local hairdresser. There are no restrictions on visiting and some residents go out regularly with family or friends; one resident goes to church every week. The home has a small garden with a bench and umbrella and some residents were sat outside on the day of the inspection, sun hats were provided and residents were helped to move about to make sure they were not sat in the sun for too long. Throughout the day residents were frequently given a choice of hot or cold drinks. The food records showed that residents have a choice of meals and residents are encouraged to have a snack in the evening. On the day of the inspection there was a choice of a hot meal or salad at lunchtime; the menus have been changed during the past couple of weeks because of the exceptionally hot weather. Because the home is small staff very quickly get to know what residents do and don’t like to eat and this is taken into account when they do the weekly food shopping. Residents said they enjoyed the food. Salroyd Villa DS0000001287.V306884.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 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 good. This judgement has been made using available evidence including a visit to the home. Residents and their representatives can be confident that their concerns will be listened to and dealt with. The home has the necessary systems in place to make sure that residents are protected from abuse, however the management team must make sure that staff that are left in charge of the home are familiar with the local authority multi-agency procedures. EVIDENCE: There is a complaint procedure in place; the home has not received any complaints since the last inspection. GPs and District Nurses have not had any complaints about the home and none have been referred to the CSCI. Residents said staff listen to them and act on what they say. The home has a copy of the local Adult Protection procedures. All staff are booked on Adult Protection training with Bradford Social Services in September and October this year, the delay is due to the high demand for this training. Staff have a good understand of what constitutes abuse and know how to report concerns within the home, however they are less clear about the procedures for contacting external agencies. Salroyd Villa DS0000001287.V306884.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, 20, 21, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents live in a homely environment that is clean, comfortable, and generally well maintained. There is only one assisted bathroom and this is likely to limit residents’ choice in relation to their preferred bathing routines. EVIDENCE: The home was clean and there were no unpleasant odours. Residents said the home is usually clean and fresh. There is an ongoing programme of refurbishment, since the last inspection the first floor corridor and one bedroom have been refurbished, and new bedding has been provided. The home had a fire safety inspection in April 2006, the home has agreed a timescale with the Fire Officer for completion of the work required, and this includes a fire risk assessment. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 17 The communal rooms are comfortable and decorated and furnished to a satisfactory standard; the deputy manager said they are planning to change the carpets in the communal areas because the highly patterned carpets can cause problems for people with visual and cognitive impairments. The bathroom on the first floor has not been upgraded; it is not accessible to residents, which means that there in only one assisted bathroom that residents can use. Most of the bedrooms were properly equipped to meet residents’ needs and were very personalised; residents had lots of their personal belongings such as ornaments, photographs, and personal memorabilia. Hot water temperatures are controlled by thermostatic valves, however the home is not doing random checks of hot water temperatures, this is necessary to make sure the valves are working effectively. The laundry is suitably equipped and gloves, aprons, and anti bacterial hand wash is available. The home is not using dissolvable bags for soiled linen, the use of dissolvable bags, that can be put directly into the washing machine, is recommended to reduce the risk of cross infection. Some of the clinical waste bins had broken lids and incontinence pads had not been wrapped in small bags before being disposed of, this creates a risk of cross infection and potentially creates an unpleasant odour. Salroyd Villa DS0000001287.V306884.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 home. There are enough staff to meet residents needs and residents are protected by the homes recruitment procedures. However to promote the wellbeing and safety of residents and staff the practice of allowing staff to work excessively long hours must be addressed. Overall staff are well trained for their roles despite shortfalls in the records relating to induction training. EVIDENCE: The home is introducing a new duty roster; this will mean that there are three staff on the day shift from 8am to 4pm. The evening shift will continue to have two staff (4.00pm to 10.00pm) and the night shift will continue to have two waking staff. In addition the home has a domestic assistant who works 4 hours a day from Monday to Friday. The new roster will give the deputy manager 8 hours a week supernumerary time and will give one of the senior care assistants an additional 2 hours a week for activities. The duty rosters showed that one member of staff is regularly working 70 hours a week, she works seven nights a week. During the week ending 16 July 06 she worked 94 hours, working through from 4.00pm to 8.00am on four of Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 19 the seven nights. This is not safe practice and contravenes the Working Time Regulations. Residents said there are usually enough staff and staff said they felt there were enough of them to meet residents’ needs. One GP commented that there is not always a senior member of staff available to deal with them. Information provided by the home showed that 50 of care staff have an NVQ qualification at level 2 or above, this meets the recommendations made in the National Minimum Standards. The home has a good training programme; the topics covered include infection control, health and safety, dementia care, palliative care and the safe management of medicines. The staff files showed that the required checks are done before new staff start work in the home. It was not always clear who had written the reference, when it was written and the date it was received in the home. The deputy manager said new staff had undergone induction training but there was no record of this. The files of some staff that have been employed in the home for some time showed that a detailed induction had been done and recorded, this practice should be reinstated. The deputy manager said staff go directly onto NVQ (National Vocational Qualification) training when they have completed their induction, the home does not use the Skills for Care Induction standards. Salroyd Villa DS0000001287.V306884.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 good. This judgement has been made using available evidence including a visit to the home. Overall the home is well managed and the interests of the residents are seen as very important to the management and staff. The management team must develop and maintain a more structured approach to evaluating the quality of the service in order to make sure that they continue to deliver a consistently good service. EVIDENCE: The management structure is clearly defined; although Mrs Elwood is the registered manager her daughter, the deputy manager, is responsible for the day-to-day running of the home. The deputy manager has the appropriate knowledge, skills, and experience for her role and has completed the Registered Managers Award. The owners continue to be closely involved with Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 21 the home mainly dealing with the accounts, maintenance, cooking and shopping; Mrs Elwood works as a member of the care staff team on a fairly regular basis. It has been approximately a year since the home issued questionnaires to residents, relatives, or other people involved with the home; the deputy manager said they were due to be issued soon. Residents and relatives are involved in care reviews and there is a lot of informal consultation with them although this is not recorded. The home does not have residents meetings. The internal auditing systems have lapsed; the deputy manager said she was looking at an alternative system for carrying out internal audits. Staff meetings are held periodically, the most recent was in June 2006, staff said they have meetings if they need them. Staff said they have regular supervision. The owner acts as agent for one resident, collecting pension money on their behalf, this is a long standing arrangement and the home no longer gets involved in residents personal finances. Some pocket money is held for residents. Receipts are obtained and records are kept of all transactions made on behalf of residents. Moving and handling training was not up to date; the home does not have a trained moving and handling co-ordinator and relies on external trainers. Training has been provided by the District Nurses on how to use the hoist. Fire training was up to date and weekly checks on the fire safety systems are done. The information provided by the home showed that the required maintenance checks had been carried out, with the exception of the checks on hot water temperatures. Accident records were completed properly and there is a system for monitoring accidents. Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 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 3 2 X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) & 17 Requirement The registered persons must Keep a record of all medicines received into the home and provide a Controlled Drugs book to record the receipt, administration, and disposal of controlled drugs. The registered persons must make sure that staff that are left in charge of the home are familiar with the local authority multi-agency procedures for Adult Protection. The first floor bathroom must be upgraded to provide a suitable assisted bathing/showering for residents. Previous timescale of 31/03/06 not met. The registered persons must check hot water temperatures to make sure that the valves are working properly and temperatures are being maintained at as close to 43 0 C as possible. Previous timescale of 31/03/06 Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 24 Timescale for action 29/09/06 2 OP18 13(6) 29/09/06 3 OP21 23(2) 30/11/06 4 OP25 13(4) 29/09/06 5 OP26 13(3) 6 OP27 12(1) 7 OP30 18 8 OP33 24 not met. To reduce the risk cross infection the registered persons must replace the broken pedal bins and provide dissolvable bags for soiled linen/clothing. The registered persons must make sure that staff do not work excessively long hours and have the appropriate rest periods in accordance with the Working Time Regulations 1998. The registered persons must make sure that all new workers have detailed induction training and they must keep a record of this training. The registered persons must establish and maintain a system for evaluating the quality of the services provided at the home. They must provide the CSCI with a report which describes the extent to which, in their reasonable opinion, the home a) Provides good quality services and b) Takes account of the views of service users and their representatives on what services are to offered and the manner in which they are to be provided. The report must include details of any measures the registered persons are going to take to improve the quality and delivery of services. The registered persons must make sure that staff receive training on moving and handling from an appropriately qualified person. 20/10/06 20/10/06 20/10/06 30/11/06 9 OP38 18 29/09/06 Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 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 3 Refer to Standard OP11 OP26 OP27 Good Practice Recommendations The home should endeavour to find out how residents wish to be cared for at the end of their lives and should record this information. Soiled incontinence products should be double bagged for disposal. The duty roster should make it clear who is responsible for cooking duties. There should be a senior member of staff available to assist health and/or social care professionals when they visit residents in the home. The reference request form should be revised to make it easier to see who has written the reference, when it was written and the date it was received All new staff should complete the Skills for Care induction standards. 4 5 OP29 OP30 Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Salroyd Villa DS0000001287.V306884.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!