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Inspection on 20/08/08 for Saxilby House Residential Care Home

Also see our care home review for Saxilby House Residential Care Home for more information

This inspection was carried out on 20th August 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

A homely, relaxed environment is provided for people who live in Saxilby House, some of the staff have been working in the home for a number of years and know the residents very well. Comments were `it`s just perfect here, I wouldn`t want to change a thing` and `staff are thoughtful, helpful and considerate`. The staff team are committed and trained and people who use the service generally felt that staff listened to them and they felt comfortable to raise any concerns.

What has improved since the last inspection?

Action has been taken to address the requirement raised in the previous inspection report and the garden area has been made secure, however, on arrival, the gate to this area was wide open and the `acting` manager told us the lock had been broken the previous day but she had made arrangements for it to be repaired. The statement of purpose and service user guide have been updated to include relevant information about the services and facilities of the home. The kitchen has been completely refitted and the service has received a five star award from the Environmental Health Officer for food safety.

CARE HOMES FOR OLDER PEOPLE Saxilby House Residential Care Home Highfield Road Saxilby Lincoln Lincolnshire LN1 2QP Lead Inspector Elisabeth Pinder Unannounced Inspection 20th August 2008 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 Saxilby House Residential Care Home DS0000059111.V370308.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. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxilby House Residential Care Home Address Highfield Road Saxilby Lincoln Lincolnshire LN1 2QP 01522 704025 01522 704025 triskelion@btinternet.com 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) Mr Colin Roy Hayes Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (10), of places Physical disability (1) Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Old Age, not falling within any other category (OP) - 10 Physical disability (PD) - 1 Dementia - Over 65 years of age (DE(E) - 2 The maximum number of service users to be accommodated is 10 2. Date of last inspection 27th October 2006 Brief Description of the Service: Saxilby House cares for older people in a family environment in a detached property situated in the village of Saxilby. The home is approximately six miles from the historic city of Lincoln. Facilities include a post office, pubs, shops, a library, chemist and a village hall. The home is a two-storey converted farmhouse standing in its own grounds and gardens with car parking facilities to the rear. There is a stair lift to the bedrooms on the first floor and there are adaptations and aids around the building to allow residents to move around the home more independently. All of the bedrooms are single. There are five communal toilets and two communal bathrooms. On the day of our visit eight people were living in the home. The current scale of charges at this home is from £351.00 to £431.00. Additional costs are made for hairdressing, chiropody, transport to personal appointments other than hospital or doctors and personal toiletries. These are all private arrangements and costs are met by the individual. Saxilby House Residential Care Home DS0000059111.V370308.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 1 star. This means that people who use this service experience adequate quality outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms ‘we’ and ‘us’ refer to The Commission for Social Care Inspection (CSCI). The visit lasted approximately six hours and we took into account previous information held by us including the previous inspection report, their service history and records of any incidents that we had been notified of since the last inspection. The Commission are trying to improve the way that we engage with people who use services so that we gain a real understanding of their views and experiences of social care services. During this inspection we used a method of working where an ‘Expert by Experience’ visited the home as part of the inspection. An ‘Expert by Experience’ is a person who, because of their shared experience of using services, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert met and talked to seven people. Before we made our visit the provider had returned the Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. However, the information in this document was very brief and did not tell us all we needed to know about the service. We sent out surveys to people before we visited the service but to date none of these have been returned to us. The main method used to carry out the inspection is called ‘case tracking’, this includes following the care of a sample of four people through their records and assessing their care. We spoke to two people who use the service and saw rooms of those people who said we could and to one staff member. The ‘acting’ manager was present throughout the visit and the general outcomes of the visit were discussed with her. What the service does well: A homely, relaxed environment is provided for people who live in Saxilby House, some of the staff have been working in the home for a number of years and know the residents very well. Comments were ‘it’s just perfect here, I wouldn’t want to change a thing’ and ‘staff are thoughtful, helpful and considerate’. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 6 The staff team are committed and trained and people who use the service generally felt that staff listened to them and they felt comfortable to raise any concerns. What has improved since the last inspection? 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. Saxilby House Residential Care Home DS0000059111.V370308.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 Saxilby House Residential Care Home DS0000059111.V370308.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): 1, 3 & 4 standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People coming into this service have access to information to help them make a decision about moving into the home, but their needs are not being assessed adequately prior to their admission to make sure they will be met. EVIDENCE: Information about the home is available in the form of a statement of purpose and service users guide, these tell people about the service. Previous inspection reports can be seen and a copy is available in the reception area of the home. The records of two people admitted since the previous inspection were examined and these did not show that a full needs assessment had been carried out prior to admission, one file did contain an ‘easy care’ plan from Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 9 Social Services and the other assessment had been written from information received over the telephone. Neither gave enough personalised information about the needs of people or showed that, where appropriate, their family or representatives were involved. There was no evidence on these files that letters had been sent confirming needs could be met. One person had been given a contract and the ‘acting’ manager said the other was currently being sorted out with the local authority. People told us they really liked living here, one person said they had lived in the home for eight years and was pleased that they had been able to stay in the village where they had lived most of their life. Another person said they didn’t think they would be able to find a better place. Relatives of a person recently admitted told us they had been able to visit the home prior to their relative’s admission and were satisfied with the care currently being provided. Saxilby House Residential Care Home DS0000059111.V370308.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. Care plans do not detail how people are able to make choices and decisions about their daily life and there is a lack of information to show that peoples’ capacity to make decisions has been fully considered which has the potential to deprive people of their rights. Medication policies and procedures are not specific to this service and this has the potential to put people at risk. EVIDENCE: The care plans of three people whose care was being followed were examined and these lacked sufficient detail to ensure staff have clear guidance on how to meet their needs. No risk assessments had been written and care plans only gave very basic details about some physical health care needs. For example, one care plan read; ‘given pain killers if she has pain at any stage,’ no other details were recorded. Another read; ‘moving aids are used,’ but did not detail what these were or how they were to be used and another read; ‘care should Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 11 be given when feeding in case chokes,’ it did not tell staff what to do in the event of choking. Care plans did not contain life histories or detail religious wishes, social stimulation, dementia health needs or end of life wishes and made no reference to the Mental Capacity Act. The ‘acting’ manager told us that she had received a copy of the Code of Practice and staff training has been arranged for September 2008. Care plans did contain signed consent forms for staff to administer medication and one person’s care plan looked at showed it was signed by the resident showing their agreement. Currently there are no male carers, therefore people are unable to choose who provides their personal care. Staff spoken to had a good knowledge of the needs of people who use the service and how to meet them and was noticed to deal appropriately with situations as they arose. A visiting district nurse also told us that in her opinion peoples physical health care needs are being met and she said staff contact her promptly if they have any concerns and always carry out instructions. The Expert by Experience reported that ‘staff spoke to all residents with dignity and respect, especially, when the needs of residents were being addressed, laughing and joking with them constantly’. She observed a member of staff was dealing with a situation promptly and appropriately regarding a person with diabetes. People told the Expert by Experience that they were more than happy with the care provided and felt their needs were being met. One person said they sometimes like a ‘lie-in’ and is served breakfast in bed. No information was available about advocacy services should people who use the service need it and the ‘acting’ manager told us that not everyone has relatives or visitors, therefore people may benefit from having access to these services. A gate is being used at the bottom of the stairs to prevent a person from going upstairs alone, and another has been put at the top of a step to prevent a person from falling during the night. We were told that all but one person are able to open these gates, however, no professional assessments for capacity have been carried out. Medication policies and procedures have been written by an external company and have the name of another service on each of them. This has the potential to put people at risk if policies are not specific to the home. For example, they refer to drugs which require refrigeration to be stored in a specific drugs fridge which this service does not have. Medication requiring refrigeration is stored in a domestic fridge in the laundry room. However, it is locked and only staff who have received medication training have access to the key. Daily temperatures are recorded and these are within the required range. The member of staff spoken to said she had received training about how to Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 12 administer medications and medication administration records were signed and codes were used where medicines were omitted. However, it was noted that the records of a person who was prescribed medication on an as required basis did not indicate whether 1 or 2 tablets were given and this has the potential to put people at risk. Saxilby House Residential Care Home DS0000059111.V370308.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 good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to have control of their daily lives. Activity arrangements are limited and may not always meet individual recreational interests and wishes of people who use the service. The meals provided are well balanced and cater for peoples’ individual preferences and specific dietary needs. EVIDENCE: Comments from people who use the service and observation during the visit showed that people have the opportunity to participate in activities, however, these are limited and do not always take into consideration individual needs. No records were available to show what activities had taken place and we were told that the activity plan on display was out of date and most people do not want to join in with organised activities, a discussion was held with the ‘acting’ manager about meeting individual recreational interests. The Expert by Experience reported that although she did not see any activities taking place during her visit, jigsaw puzzles, DVD’s, CD’s, books, magazines & newspapers were available. Religious needs are met individually, one person Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 14 has a vicar visit monthly. Another person uses a mobility scooter and regularly visits the pub or has a ride around the village where they lived most of their life and knows people said, ‘it’s just perfect here, I wouldn’t want to change a thing’. However, no risk assessment had been written regarding the health and safety of this person, other people or the condition of the scooter. People said they were able to keep in touch with family and friends and have visitors and this was evident throughout our visit. They told us that the food is ‘very good’, the cook has been working in the home for many years and has a good understanding of peoples’ likes and dislikes. She told us that she is currently writing new menus after talking with people to ensure they have the food they like and choose. Menus currently being used showed that a varied nutritious diet is offered and people are able to choose each day what they want. The menu of the day was displayed on a blackboard in the dining room. The Expert by Experience reported that the mealtime was ‘a stress free, relaxed occasion, staff were sensitive to residents needs’ and they told her that if there was anything on the menu that they disliked an alternative is offered. Saxilby House Residential Care Home DS0000059111.V370308.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 good. This judgement has been made using available evidence including a visit to this service. People are protected by the home’s procedures for handling complaints and allegations of abuse and they are confident that their complaints or concerns will be taken seriously. EVIDENCE: Information in the AQAA read ‘we support anyone wishing to make a complaint, record issues and act promptly’. People living in the home have all been given the complaints procedure and it is on display. They told us they know how to make a complaint or raise a concern if they need to and they feel safe living here. People said staff listen to what they have to say and take any necessary action and two relatives spoken to told us they would feel confident to raise any issues if necessary. Policies and procedures are in place such as whistle blowing and confidentiality but, as previously highlighted, these have not been specifically written for this service. The staff member spoken to had a good understanding of the complaints process and how to deal with any allegations of abuse. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 16 Records show that one complaint has been made about the home since the last inspection and this was dealt with by the provider. No further complaints have been made and no referrals have been made to Safeguarding Adults. Saxilby House Residential Care Home DS0000059111.V370308.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. People live in a safe and comfortable home, which meets their needs. EVIDENCE: People said they found their rooms to be comfortable and were able to arrange them to their liking and make them more personal with items of their own choice. The Expert by Experience spoke with two people in their rooms and saw that mobility equipment was provided in one of them, both had fruit baskets and jugs of water or juice and emergency call bells were within reach for each person. Windows on the first floor have been secured to prevent them from opening too wide and safety measures have been taken to enable people to walk around the gardens independently. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 18 Information provided in the AQAA told us that within the last twelve months three bedrooms have been redecorated and re-carpeted together with the lounge and upstairs landing. Plans are in place to provide a walk in shower room but this is currently on hold due to recent problems with damp and subsidence which are being addressed. Since the previous visit the kitchen has been completely re-fitted and the service has received a 5 star award for food safety from the Environmental Health Officer. Staff told us protective aprons and gloves are always available to use when needed. Saxilby House Residential Care Home DS0000059111.V370308.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for people living in this home. The service recognises the importance of training to ensure staff are knowledgeable and equipped to meet the needs of people living here. However, there are shortfalls in the recruitment process that may put people at risk. EVIDENCE: There are currently eight people living at Saxilby House and two members of staff are on duty between the hours of 07:00 and 22:00. The ‘acting’ manager’s hours are included in these and there is one wakeful night staff. The ‘acting’ manager lives on the premises and is on call throughout the night. The Expert by Experience reports reads, ‘the atmosphere between service users and staff appeared very friendly, calm and very relaxed’. People told her staff are ‘kind, thoughtful, helpful and considerate’. Three new staff have been employed since the previous inspection and records checked were incomplete. The ‘acting’ manager confirmed that their application forms and completed CRB/POVA checks were with the provider and Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 20 although he offered to fax these to us it was advised that these are kept on the premises for future inspections. Records only contained one reference for each of them and a discussion was held around the number of references needed and that where applicable, one should be from the applicant’s previous employer. Records showed that the new staff have started induction training and the member of staff spoken to told us she receives regular training updates and was aware of the planned training regarding the Mental Capacity Act. Information provided in the AQAA told us that 29 of staff have achieved a nationally recognised vocational award in care and the service has registered with Skills for Care Council for induction training. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a potential risk to people living in this service due to the excessive hours being worked by the acting manager. EVIDENCE: Since the previous visit the manager has retired and an acting manager is in post and she is currently applying to be registered with us. We were told that the ‘acting’ manager is often working from 09:00 until 22:00 or 15:00 and throughout the night. Her role is mainly care and she is finding it difficult to complete management responsibilities. She has not had any formal supervision from the provider, although, she was given some support from the area manager until June to set up care plans. People spoken to liked the new Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 22 manager and all knew her by her christian name. One person told the Expert by Experience ‘she mucks in just like the rest of them’. Staff said they found her to be approachable and available to offer support to do their job, however, they said they were concerned about the amount of hours she worked. Staff records showed that supervision is not up to date, one member of staff has not had any formal supervision since January 2008, another March 2008. Some people told the Expert by Experience that they were generally unable to offer views or opinions about the service but three people said that if staff make suggestions they are always asked if they were in agreement. The ‘acting’ manager told us that she has recently sent quality assurance questionnaires to residents and their relatives and a discussion was held about asking other stakeholders, for example district nurses, social workers and General Practitioners for their opinions of the service. When questionnaires have been returned, a report reviewing the quality of care should be written and sent to us. The manager said she has received a copy of the Department of Health guide ‘Essential Steps’ regarding infection control management but to date has not had the opportunity to include this in health and safety policies. Records showed that fire equipment checks and fire evacuation drills and training are carried out regularly. Information provided prior to the visit told us that equipment and appliances are regularly serviced and a sample of records checked on the day confirmed this. Accident/incident records are in place and we are informed of any incidents that require reporting. However, records of monthly reports written by a representative of the company have not been written since May 2008. Records of monies held on behalf of people whose care was being tracked were examined and these were accurate and up to date. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 3 Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14[1] [a] Requirement A full needs assessment must be carried out prior to admission to ensure peoples’ needs will be met. Written confirmation of the outcome as to whether the service is suitable to meet their needs or not must be sent to people before they move into the home to assure them their needs will be met. Care plans must be in more detail to ensure that peoples’ needs are met. Care plans must take into consideration the Mental Capacity Act 2007. Risk assessments must be written. Policies and procedures for recording, handling and storage of medicines must be written specifically for this service to ensure safe procedures are followed. Appropriate activities and leisure opportunities for residents to participate in must be provided to meet individual needs. DS0000059111.V370308.R01.S.doc Timescale for action 01/10/08 2. OP4 14[1] [d] 01/10/08 3. OP7 15 [1] 13[4] [b,c] Mental Capacity Act 2007 01/10/08 4. OP9 13[2] 01/10/08 5. OP12 16[2] [n] 01/10/08 Saxilby House Residential Care Home Version 5.2 Page 25 6. OP29 19[1] [b] 7. OP36 12[1][a] 8. OP36 18[2][a] 9. OP37 26[1]& [4][c] Records must demonstrate a satisfactory recruitment procedure, which include obtaining two satisfactory written references for each employee. This will help to ensure that residents are well protected. The manager must have sufficient time to monitor the quality of the service to ensure people living in the home receive good standard of care. All staff must be appropriately supervised to ensure they have the necessary skills to care for residents. Reports must be written by the registered provider after each monthly visit regarding the conduct of the home to ensure people living in the home are receiving a good standard of care. 01/10/08 31/10/08 31/10/08 01/10/08 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 OP7 OP33 Good Practice Recommendations It is recommended that care plans contain a life history of people and this information is taken into consideration to ensure appropriate care is provided. It is recommended that regular residents meetings are held and minutes are taken to ensure people are able to have their say about the running of the home. Saxilby House Residential Care Home DS0000059111.V370308.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Saxilby House Residential Care Home DS0000059111.V370308.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. 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