Inspection on 06/12/05 for Scarletts

This inspection was carried out on 6th December 2005.

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

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

Other inspections for this house

Scarletts 17/07/08

Scarletts 25/07/07

Scarletts 17/08/06

Scarletts 09/06/05

Scarletts 12/10/04

Scarletts 18/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Scarletts Recreation Road Colchester Essex CO1 2HJ Lead Inspector Kathryn Moss Unannounced Inspection 6th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Scarletts Address Recreation Road Colchester Essex CO1 2HJ 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) 01206 792429 01206 870694 Southend Care Limited Mrs Mandy Faires Care Home 63 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (63) of places Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One named person, aged 65 years and over, who requires care by reason of dementia, whose name was made known to the Commission in January 2003 Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 63 persons) The total number of service users accommodated in the home must not exceed 63 persons 9th June 2005 Date of last inspection Brief Description of the Service: Scarletts Residential Care Home is a purpose built care home for older people, located close to Colchester town. It accommodates up to 63 people, in 31 single rooms and 16 double rooms. Accommodation is on two floors, with a passenger lift providing access to the first floor, a variety of communal lounge areas, a large dining room, and pleasant grounds. Scarletts is registered to provide care to 63 older people (over the age of 65). The home provides 24 hour personal care and support, and has appropriate aids and equipment (e.g. mobile hoist, assisted bathing facilities, hand rails, etc.) to assist residents with limited mobility. The home does not provide nursing care and is not registered to admit people with dementia: a condition of registration allowed the home to continue caring for a person with dementia who was living in the home prior to the implementation of the Care Standards Act. As this person is no longer living in the home, this condition will now be removed. The home is owned by Southend Care Ltd, and the registered manager is Mandy Faires. The manager and the deputy manager were present and participated in the inspection. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 6/12/05 and 7/12/05, lasting 13 hours. The inspection process included: discussion with the manager and with five staff; discussion with eight residents; a tour of the premises; and inspection of a sample of records. Comments and judgements in this report are based on information and observations gathered on the day of the inspection, and on any complaints received since the last inspection. On the day of the inspection there were 54 residents living in the home. 17 standards were covered, and 5 requirements (two of which were repeat requirements) and 12 recommendations have been made. The main focus of this inspection was on environment and health and safety issues. Information on core standards not covered in this report can be found in the report of the unannounced inspection that took place on 9.6.05. During the inspection, residents spoken to appeared content with their lives at Scarletts, and were positive about the care and assistance they received from staff. What the service does well: What has improved since the last inspection? The manager stated that staff had concentrated this year on developing activities, and there was evidence that both activities and social events were regularly taking place. Activities were seen taking place on the inspection, and there had been a number of ‘parties’ during the year. Of particular note was a coach trip to Clacton in summer, when staff took 45 residents out for the day. This had clearly been enjoyed by residents , and staff should be commended for the time and effort put into arranging and carrying out such an event. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Pre-admission assessments enabled staff to determine if the home could meet a prospective resident’s needs, and residents were confidant that staff were able to meet their needs. EVIDENCE: Residents spoken to appeared well cared for: they praised staff, and were happy with the way staff met their needs. There was evidence that the home had the facilities and equipment available to meet the needs of the individuals who the home aimed to meet. Staff showed knowledge of residents’ needs, and of how these needs were being met. The manager and senior staff are clear on the needs the home aims to meet, and staff training was provided appropriate to the needs the home aims to meet (see Standards 30 and 38). Prospective residents are assessed prior to admission by someone from Southend Care (not necessarily from Scarletts), and care management assessments are obtained for residents referred through social services (evidence not viewed on this occasion). The file of one new resident viewed contained an assessment form completed prior to admission: this was a Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 9 standard form with a list of set statements regarding abilities or needs, which were ticked to select issues relevant to the person. Some details recorded appeared contradictory (e.g. both ‘able to understand freely’ and ‘has limited understanding’ were ticked; ‘unable to engage in social interaction’ was ticked, but other information indicated that they were alert and could communicate), and it would therefore be useful if staff carrying out pre-admission assessments could record fuller information about peoples’ individual needs. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Health and personal care needs were set out in individual care plans, but these did not satisfactorily cover all key needs and provide sufficient details of the action required by staff. EVIDENCE: Service users spoken to were satisfied with the support staff gave them, were very positive about all the staff, and looked well cared for. Staff spoken to were able to describe the home’s practices with respect to continence care (regarding regular checks on continence pads and toileting needs). When asked what they felt could be improved upon, one resident felt that staff could sometimes be quicker in taking them to the toilet, although acknowledged that sometimes staff were busy. Healthcare records and issues (other than care plans) were not specifically inspected on this occasion. Two care plans were viewed with the manager, and a further two with the deputy manager. There was a noticeable improvement in these, with evidence that staff had generally identified and completed the relevant care plan forms to cover each key personal care need, had sometimes added some additional and relevant information about the person’s need or the action required of Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 11 staff, and were reviewing these regularly. However, in some cases the care plans still needed more detail of the action required by staff to meet the need (e.g. care plans relating to ‘inability to self-toilet’ did not detail what assistance the person actually required), and in one file there was no care plan to address the person’s need for assistance with feeding. Another file for a person who had recently been discharged from hospital with greatly changed needs had not been updated: care plans for risk of falls and personal cleansing therefore did not reflect current needs, and there were no care plans to reflect their need for assistance with feeding, incontinence, and pressure area care. It is important to update care plans promptly when needs change significantly, and further action on care plans is therefore required. Medication practices were not fully inspected on this occasion. At the last inspection a requirement was made regarding the recording of medication brought in by new residents on admission: on this inspection the records for two new residents showed that their medication had been checked and recorded on the Medication Administration Record (MAR) on admission. It was noted that some of the hand written medication details did not specify the frequency of the dose, and staff were reminded to ensure that medication administration instructions are fully recorded on the MAR. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Residents spoken to felt that the lifestyle at Scarletts met their needs, and that they had some choice and control over their lives. The home provides a balanced diet in pleasant surroundings. EVIDENCE: Daily routines in the home appeared flexible, with people being able to chose when to get up, where to spend their day and whether to join in with activities. The manager reported that the staff had focused on activities this year, and felt that there had been significant improvements in the activities taking place within the home. There was a weekly activities programme, and staff were allocated each shift to do activities: during the inspection, one resident was seen making Christmas decorations, and another group of residents were seen colouring in Christmas pictures; a staff member was seen spending time with a group of residents and interacted well with them. The manager reported that as well as ongoing activities such as bingo, reminiscence and quizzes there had been regular events such as a Halloween tea party, a summer fete, a meal out in Brightlingsea (seven residents went), and a visit by a Colchester radio station; it was noted that a Christmas party was advertised. During the summer, the home had hired a coach and arranged a trip to Clacton, taking 45 residents out for the day: residents spoken to had clearly enjoyed this, as shown also from a display of photos taken on the outing. A lot of work was Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 13 involved in organising such a trip, and the manager and staff are commended for this. Records of activities were not inspected on this visit. From observations during the inspection it was clear that staff encouraged residents to exercise choice in their daily lives (e.g. in relation to what to wear, where to sit, meals, activities, etc.). From rooms viewed it was clear that service users were encouraged to personalise their rooms with their own possessions. On previous inspections it was noted that the Resident’ Handbook stated that service users could access their personal records. Control of finances and access to advocacy services were not discussed on this occasion. Menus were not specifically inspected on this occasion, but residents spoken to stated that they were happy with the meals provided to them and felt that the meals were generally very good. It was noted that the day’s menu was displayed on a board outside the main dining room, and showed choices available; residents spoken to confirmed that there was a choice at each meal time. An upstairs lounge that had its own dining area did not have a menu displayed, and this is recommended. It was noted that breakfast was still being served at 10am and that residents spoken to had enjoyed their breakfast; it was good to see that breakfast was flexible and unrushed. There were no cold drinks available in one of the lounges viewed, and two residents spoken to said that they would like cold drinks to be available. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 In relation to staff training, the home has taken appropriate steps to ensure that residents are protected from abuse. EVIDENCE: Staff training in the Protection of Vulnerable Adults (POVA) was the only issue specifically covered on this occasion in relation to Standard 18. It was noted that all apart from three care assistants had now attended a POVA workshop: the manager advised that there were further workshops due to take place, and that all carers and auxiliary staff had attended an internal ‘abuse awareness’ session led by a senior carer. Staff spoken to confirmed that they had attended the workshop and/or the in-house abuse session, and showed awareness of the issues. One carer had produced a good piece of written work describing Whistleblowing and abuse. Complaints were not specifically inspected. Just one complaint had been received by the CSCI since the last inspection, and the manager was advised of this on the inspection and confirmed that this would be looked into. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26 The home provides a safe environment, with systems in place for repairs and maintenance. The home provides service users with sufficient personal and communal space, which was suitably furnished; however, action was needed to protect hot radiators and there were insufficient electric sockets in residents’ rooms. On the day of the inspection the home was clean and hygienic; however, procedures for washing soiled linen were not satisfactory. The home provides appropriate toilet and bathroom facilities. EVIDENCE: On the day of the inspection, the home appeared safe and well maintained. The home had a maintenance person who was responsible for maintenance and decoration, and for some health and safety issues within the home; the home kept a record of decoration and refurbishment carried out. As noted at the last inspection, some furniture in the home was becoming worn and in need of replacing, and some carpets were marked. However, as part of a Business and Development Plan being developed for the coming year, the Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 16 manager stated that she had identified rooms that needed decoration or carpeting, and said that finance had been agreed for some new furniture. The home has several communal lounges (one with dining space) and a large dining room; a hallway and an upstairs landing area also contained some seating that was well used by residents, who reported that they enjoyed sitting there as they could watch what was going on. Communal areas were clean and tidy, provided a good range of space, and could be used for a range of social activities. Some lounge furniture and carpets were becoming worn, and in one lounge it was noted that there were very few side tables on which residents could place drinks or personal belongings. One lounge was used for smoking, and it was good to see that the flooring had recently been replaced with a floor covering suited to the use of that lounge. Some paintwork in lounges and corridors was marked and in need of repair. A sample of bedrooms viewed were mostly in a reasonable state of decoration, but had some damage to walls or wallpaper that would benefit from repair. Rooms generally had sufficient and suitable furniture, subject to space constraints in some cases; a few had marked carpets or worn furniture (e.g. a chest of drawers with a handle missing, etc.). As noted on previous inspections, rooms had insufficient electric sockets to meet residents’ needs: many table lamps or other equipment (e.g. a TV) were not plugged-in as there were no available sockets; in one shared room viewed there was no socket on one resident’s side of the room. This needs to be addressed. Rooms viewed had lockable storage facilities and locks on doors: residents spoken to did not have keys to these, but the manager stated that keys were available. The manager was asked to ensure that the option of lockable storage and keys to their rooms is actively offered to residents: it was noted that the design of door locks would not allow staff to override these from the outside, and this must be addressed if any resident requests a key to their room. Not all bathrooms were inspected on this occasion, but those viewed provided assisted bathing facilities in pleasant environments, and were clean and tidy. Only eight bedrooms had ensuite toilets; other rooms had access to a range of toilet facilities located around the home, fitted with appropriate aids as required (e.g. raised toilet seat, grab rails, etc.). There were systems in place to monitor hot tap water temperatures (re risk of scalding), and for monitoring central hot water temperatures (re risk of Legionella). Radiators were unguarded: at an earlier inspection the inspector had been advised that these were kept at a safe temperature; however, on this occasion one was noted to be quite hot to touch. The manager reported that the maintenance person had started work to fit appropriate guards, and was initially prioritising radiators in bathroom areas. Addressing risk of scalding through restricting the radiator temperatures will prevent residents’ ability to control the temperature in their rooms, and therefore action to fit appropriate guards where risk is identified should be progressed. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 17 On the day of the inspection the home was clean and tidy and generally free from unpleasant odour, although there was a strong odour in one area of corridor, which staff thought was due to the proximity of a particular room where a resident had some continence problems. The home had guidance on Infection Control for Care Homes, and disposable protective gloves and aprons were available to staff. The home had two sluice rooms equipped with automatic sluice disinfectors, and a laundry room that was located away from areas where food was prepared or stored. Some issues were identified regarding infection control practices within the laundry: although washing machines had a sluice wash cycle, this did not appear to be regularly used because of the length of time this occupied the machine for just a few items. Instead, soiled items were being sluiced by hand in the laundry sink, which was also the only sink available for hand washing clothing and washing hands. Additionally, although the washing machines had scope to wash soiled items at 65°C or 71°C for infection control purposes, signs were fixed to the washing machines stating that no washes should be at more than 50°C, and the laundry person confirmed that they had been following this instruction. The manager was advised that a clear protocol needed to be developed for all staff, to address infection control practices in relation to the handling and washing of soiled laundry. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 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 and 29 At the time of this inspection, staffing levels were meeting residents’ needs. Recruitment practices protected residents, but needed some further action in relation to records. EVIDENCE: At the time of this inspection, only 54 out of 63 beds were occupied within the home. Because of the lower residency levels, the home had been operating on nine staff throughout the day instead of ten staff in the mornings (the agreed level for the home). The manager, deputy manager and a senior spoken to felt that this level of staffing was meeting current residents’ needs; it was agreed that this continued to be sufficient for he current number and dependency of residents, but will need reviewing as occupancy rises again. Rotas were viewed for the week of the inspection and some previous weeks, and showed that this level of staffing was generally being maintained, although there were a few shifts each week when there was one staff less (eight staff) due to last minute sickness. Domestic staffing levels had significantly improved since the last inspection, with some weeks in October showing three domestic staff on duty most days (and two staff on other days). However, there had again been some recent weeks when there had only been one domestic person on duty on one or more days: in a home of this size, this is not sufficient domestic cover. There was a separate laundry person on duty five days a week. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 19 The files of three new staff were viewed, and each contained completed application forms showing employment histories; in one case there was no written explanation of a gap in the employment history. All contained the names of two referees and two references obtained before the person started work; however, in one case the references consisted of a testimonial and a record of a verbal reference, neither from the named referees indicated on the application form. The deputy manager explained that they had had difficulties obtaining references, and was advised that this should be clearly recorded. Files contained evidence of ID, photos, a health questionnaire and a declaration of criminal record. None of the files contained evidence of when the provider had received a CRB check for the person, but the inspector had recently enabled viewed CRB checks held centrally by the provider, and it was noted that a CRB check had been received for each applicant shortly after they had started work. The manager was advised to evidence this on each file (e.g. date and number of disclosure), to demonstrate that she had complied with regulatory requirements. For two people there was evidence of a POVAfirst check obtained before the person started work; the third person had been recruited from overseas prior to recent advice given to the provider clarifying the need to obtain CRB/POVA checks on overseas staff before they start work; however, there was no evidence on file of a police check from the person’s country of origin. Training was not specifically inspected on this occasion, but it was good to see that six more staff had recently started NVQ training. The home maintained a training matrix showing when staff last attended core training. Health and safety training is covered in the next section, but other evidence seen showed a variety of other training that had taken place this year, including: in-house sessions on basic care tasks (‘Bed Making, Standard of Care, Residents’ Rooms, Attitude to Residents, Care Planning’) led by the deputy manager or senior carers, POVA training, continence training, three seminars by a funeral service, bereavement training, diabetes training, food hygiene, and Chronic Obstructive Pulmonary Disease. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 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): 35 and 38 Residents were safeguarded by the home’s procedures for the safekeeping of their money. Practices in the home promoted the health and safety of staff and residents; however, not all staff had received fire safety training. EVIDENCE: The home had clear systems for looking after money held on behalf of residents. Limited amounts of cash were held for them: there were secure storage arrangements for this, money was kept in individual bags and clear individual record sheets were maintained with receipts for any purchases made. One person’s money and records were sampled and the cash, receipts and records all balanced. The home also operated a residents’ bank account, into which residents could place larger sums of money for safe- keeping, and clear individual records were maintained of any monies held in this account. The provider has previously advised the CSCI that this account is only used for residents’ monies, non-interest and is not part of the company’s assets. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 21 The home’s policies and procedures on health and safety were not specifically inspected on this occasion. Health and safety practices within the home generally appeared safe, appropriate and well maintained: the main issue highlighted related to laundry practices, and this has been referred to in the Environment section. The manager maintained a clear and well organised record of external checks and servicing carried out on equipment and utilities, which provided evidence that the equipment and premises were regularly maintained. The Landlord’s Gas Safety check certificate did not indicate that equipment had been serviced, and the manager was advised to ask the engineer for written confirmation of this in future. The maintenance person carried out and recorded regular internal checks on hot water temperatures, which showed that hot water taps were maintained close to 43°C to prevent risk of scalding, and central hot water storage temperatures were above 60° to prevent risk of Legionella. There was also evidence of regular checks on fire alarms, emergency lighting, and fire equipment, as well as fire drills being carried out each month. Accident records and risk assessments were not inspected on this occasion. Staff training records showed evidence that the 24 care staff (including the manager) all had current manual handling training, 17 had emergency aid training, and 16 had food hygiene training. Training records showed that of the 30 staff (care and ancillary) currently employed, only 17 had attended fire safety training: the manager stated that new staff cover fire safety procedures as part of their induction, and therefore a further five staff would have covered this; there was evidence of a Fire Precautions and Procedures checklist completed and signed by the carer and their supervising senior. There remained 8 staff for who there was no evidence of fire safety training: other than induction training, no fire safety training had been provided since the last inspection, and this should be addressed. Policies and procedures were not specifically inspected on this occasion, but it was noted that a new book of procedures for Scarletts’ senior carers had recently been implemented by the manager, detailing local arrangements for practices such as admission and discharge, Regulation 37 notices, missing persons, RIDDOR, complaints, etc. This was a useful and clear document, which was well produced. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 3 X X 2 2 2 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must be developed further, to cover all of a person’s needs (personal/health care, mental health and social), and to include clear details of the action required by staff to meet each need. Care plans must be updated when a resident’s needs change. This is a repeat requirement for the second time (last timescale 31/7/05). The registered person must review the decoration and furnishings of the home and take action to ensure that these are satisfactorily maintained (ref Recommendations 4-8). The registered person must implement procedures for the handling and washing of soiled laundry that meet infection control guidelines. The registered person must ensure that there is a written explanation for any gaps in an applicant’s employment history. DS0000017928.V271710.R01.S.doc Timescale for action 31/01/06 2 OP19OP20 OP24 16(2) and 23(2) 31/03/06 3 OP26 13 and 16 06/01/06 4 OP29 19 and Schedule 2 31/03/06 Scarletts Version 5.0 Page 24 5 OP38OP30 18 and 23(4) The registered person must ensure that all staff have received current fire safety training. This is a repeat requirement (previous timescale 30/9/05) 31/03/06 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 4 Refer to Standard OP3 OP15OP8 OP15 OP19OP20 OP24 OP20 OP24 OP24 Good Practice Recommendations It is recommended that the registered person ensure that pre-admission assessments clearly describe a prospective resident’s needs. It is recommended that staff ensure that there are cold drinks always available in lounge areas, and that these are regularly offered to residents. It is recommended that the daily menu be displayed in the Sunbeam lounge/dining area. It is strongly recommended that the registered person take action to replace or repair any worn furnishings, fittings and decoration in communal areas and individual bedrooms. It is recommended that side tables are provided in lounge areas alongside each chair. The provider should ensure that all bedrooms have sufficient electrical sockets to meet residents needs. Staff should ensure that keys to their lockable drawer or bedroom door are actively offered to residents. Where residents choose to hold a key to their door, the registered person should ensure that the lock is of a design that can be overridden from the outside. The registered person should progress action to minimise risk from hot radiator surfaces (e.g. through the fitting appropriate low temperature guards). The registered person should ensure sufficient domestic staff are on duty each day to maintain the cleanliness and hygiene within the home, and that there are contingency plans for covering staff shortages. DS0000017928.V271710.R01.S.doc Version 5.0 Page 25 5 6 7 8 9 OP25 OP27OP26 Scarletts 10 OP29 11 OP29 12 OP38 The registered person should ensure that appropriate references are obtained for all staff applicants. Where the home has difficulty obtaining a response from a referee, action taken to progress this should be evidenced, and reasons for approaching alternative referees (and the capacity in which they know the applicant) recorded. Testimonials brought in by an applicant should not be accepted without verification from the referee. The registered manager should maintain evidence on file of when an applicant’s CRB check was received: if CRB checks are held at head office, then it is recommended that the disclosure number and date should be recorded on the file, as evidence that regulatory requirements have been met. The registered person should ensure that evidence of the servicing of gas appliances is maintained in the home. Scarletts DS0000017928.V271710.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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