Inspection on 28/10/08 for Seton Unit

This inspection was carried out on 28th October 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seton Unit 21/11/06

Seton Unit 02/02/06

Seton Unit 07/07/05

Seton Unit 13/01/05

Seton Unit 21/09/04

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 17/12/2008.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Seton Unit The Marillac Eagle Way Warley Essex CM13 3BL     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Bernadette Little     Date: 2 8 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Seton Unit Eagle Way The Marillac Warley Essex CM13 3BL 01277220276 01277204060 seton@marillac.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Sister Anne Christina McGuinness Type of registration: Number of places registered: SISTERS OF CHARITY OF ST VINCENT DE PAUL care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Personal care to be offered to no more than 8 older people over the age of 65 years (OP). Personal care to be provided to no more than 8 service users with dementia over the age of 65 years (DE(E)). The number of service users to whom personal care is to be offered shall not exceed 8 (eight). Date of last inspection Brief description of the care home The Seton Unit is a small Care Home for eight people. It is situated on part of the first floor of the Marillac Nursing Home. All the residents are Sisters of Charity of St Vincent de Paul and the Home provides facilities and an environment which supports their Care Homes for Older People Page 4 of 29 0 0 Over 65 8 8 Brief description of the care home spiritual needs. There is an attractive lounge/diner and a separate well-equipped activities room. Each single room has ensuite facilities. Meals are provided from the main kitchen, however snacks and drinks are produced in the Homes own kitchen. The Seton Unit has a pleasant rooftop garden, as well as access to the grounds of the Marillac. The Service User Guide and Statement of Purpose have been reviewed and are updated as required. The residents and their representatives can be provided with this information and the manager stated previously that the home would provide them with Commission for Social Care Inspection reports too. These can be displayed for reference. The updated statement of purpose identifies the current fees for the year 2008-2009 as 430 pounds per week. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The site visit was undertaken over a six-hour period by one inspector as part of the routine key inspection of the Seton Unit. Time was spent with residents and staff and information gathered from these conversations, as well as from observations of daily life and practices at the home have been taken into account in the writing of this report. The manager submitted an Annual Quality Assurance Assessment (AQAA) as required prior to the site visit. This is required to detail their assessment of what they do well, what could be done better and how they plan to improve. This information was considered as part of the inspection process. Care Homes for Older People Page 6 of 29 We sent the manager a number of surveys to distribute to residents, visitors, staff and other professionals. Completed surveys were received from three residents. The information they contained as well as the comments made are included in this report. A tour of the premises was undertaken and records, policies and procedures were sampled. The manager was present for most of the site visit and assisted with the inspection process. The outcomes of the site visit were fed back and discussed with the manager and opportunity was given for clarification where necessary. The assistance of all those at the Seton Unit was greatly appreciated. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 29 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People thinking of living at the Seton Unit will have a full assessment of their needs to make sure the service can meet them and will be given enough information on which to base a decision to live there. Evidence: A copy of each of the current statement of purpose and service user guide was provided on request. These contained appropriate information, although they should be amended to identify that the service is no longer registered with Essex County Council. There was evidence on a residents file that confirmed a copy of the service user guide had been provided to them. Surveys received from residents confirmed that they had been given enough information about the service before moving in and that they had each been issued with a contract of terms and conditions. Care Homes for Older People Page 11 of 29 Evidence: The Annual Quality Assurance Assessment (AQAA) and the service user guide explain that a detailed assessment would be undertaken of the persons needs by a member of staff at the prospective residents own home. This would be to provide the prospective resident with information about the unit and to make an initial assessment of their needs from which a preliminary care plan would be drawn up. The file of a recently admitted resident was reviewed and it contained an assessment of the persons needs. This assessment was not dated or signed by the assessor or the resident to evidence that this had occurred prior to admission. This had been a recommendation in the last key inspection report. The format of the pre-admission assessment document did not include a prompt to sign and date it and the new manager confirmed that they will address this. The manager stated that they had recently visited a prospective resident in their current care environment to undertake a detailed pre-admission assessment of their needs. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Seton Unit can expect good care outcomes that meet their expectations and needs and respect their privacy and dignity. Evidence: Care plans for two residents were reviewed. A photograph was available on one of the two files to support identification. The care plans contained basic standard headings but identified individual needs in line with the preadmission assessment for each person. There were instructions for staff on how to meet each persons needs in daily practice. Aspects of the care plan were signed by the resident to show their agreement, which is good practice. Care notes were written daily and these vary in quality with some being repetitive. Guidance was provided to the manager on how good quality care notes can be used as a monitoring tool to gauge the effectiveness of the care plan or need for changes. Care plans had evidence of review and changes to a residents need and ability had been identified and supported to encourage developing independence. This was Care Homes for Older People Page 13 of 29 Evidence: supported by a current risk assessment. Risk assessments were also in place for basic issues such as moving and handling or bathing and for more person centered individual issues such as driving, self-management of medication or walking outside. The moving and handling assessment was not dated so it was not clear when it was last reviewed to ensure that it was current. All residents spoken with said they were satisfied with the care and support they received. This was also confirmed in resident surveys received and that staff are available when they need them and listen and act on what they say. One person said they dont impose themselves on us, they give us the help we need but allow us to do the things we can manage to do for ourselves. This confirms the information in the AQAA that advises that each resident is supported to make their own decisions and that care workers are trained in giving choices. Care plans reviewed included a section on medical needs and a record of health professional interventions, with supporting notes. This confirms the information in the AQAA that residents have access to optician, chiropodist, dentist and physiotherapist. Records also showed that residents are supported to access other services such as the district nurse and GP as appropriate. Information from residents spoken with and from surveys confirmed that residents receive the medical support they need. A monitored dosage medication system was in use. Some residents were selfmedicating through choice, supported by risk assessment. The medication blister packs for each person were stored individually in locked cabinets in their own personal rooms along with their medication administration records. Records sampled were upto-date and the medication remaining tallied. However a number of omissions were noted where staff had not signed the record or included an appropriate code if for some reason the medication had not been administered. Controlled drugs were maintained in a metal lockable cabinet in a separate area. A controlled drugs register was maintained, appropriately counting down remaining drugs and including the signatures of two staff for administration. A record was maintained of medication received and returned. It was noted positively that where general medication was prescribed in a way that allowed a resident one or two tablets, the number administered was recorded. Staff spoken with confirmed that they had received medication training recently and this was evidenced in the staff training files reviewed. There was evidence in the care records that confirmed the information in the AQAA that residents have routine medication reviews and opportunity to speak to their GP regarding their medication. Care Homes for Older People Page 14 of 29 Evidence: Residents spoken with said that staff respect their privacy and dignity, for example when they are bathing, or by knocking on doors and always waiting to be invited to come into the room. Care plans identify the persons preferred form of address and residents spoken with confirmed that staff respect this. Discussions with staff confirmed this, as did observation of practice during the site visit. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the Seton Unit can expect to exercise choice and control over their lives and enjoy a range of activities and meals that meet their needs. Evidence: Care plans identified clearly peoples interests and preferences for social activities. They also contained a my lifestyle sheet which gives an indication of the persons preferred routines. Care notes showed a variety of activities for people in line with their preferences, for example going out for a walk, looking after plants, attending prayers and Chapel, having visitors and going out for drives, shopping or to their community house. Information on the activities planned in house for the day was displayed on the board in the hallway, along with details of the staff on duty. Residents spoken with confirmed that they have choice and control over many areas of their daily life including what they eat,wear and what they do each day. Some residents sat in the activity room after morning mass for coffee or to read the paper. This room is equipped with a computer with Internet access, a comfortable seating area for reading or chatting, an organ, and books puzzles and games. Residents said that there are volunteers who come in to do activities with them such as making Care Homes for Older People Page 16 of 29 Evidence: Christmas cards. One resident said I dont have enough time to do all the things I want to do each day. Residents also advised that that enjoyed a weeks holiday together earlier this year and that there are visitors in the home regularly. Surveys received from residents confirmed there are always activities arranged that they can join in with and one person said I enjoy activities arranged by the home and am able to take part in all of them. Meals are cooked in the main kitchen of the Marillac care home. Residents confirmed that they enjoyed the quality and choice of meals and drinks provided. Some residents chose to eat lunch together at a pleasantly set table in the dining room, while others chose to eat in their room. Choices at lunchtime were lamb hotpot, chicken kiev or butter bean casserole with accompanying vegetables. Comments from resident meetings indicate concern that meal portions are too big and result in wastage. Resident surveys received confirmed satisfaction with the meals and included the comment always alternative menus provided with a wide choice. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the Seton Unit can expect to be listened to and to be safeguarded by effective procedures and staff knowledge. Evidence: A complaints procedure was readily available, displayed on the unit and included as part of the service user guide. Guidance was provided to the manager on clarifying that the commission does not investigate individual complaints but that people could also approach social services. In the AQAA, the manager states that service users have access to independent advocates. Surveys received from residents confirmed that they would know how to make a complaint and would know who to speak to if they were unhappy. One person commented that as a member of a religious congregation, they had not only the local contacts but also had the advantage of speaking to their councillors and Provincial, the head of the congregation. Residents spoken with said they would feel able to tell somebody if they were unhappy or had a complaint and one person said I would tell everybody. A logging system for complaints was available although there had been no entries for some years. The manager confirmed the information in the AQAA that no complaints had been received. The commission has not received any complaints about the service Care Homes for Older People Page 18 of 29 Evidence: since the last inspection. The manager confirmed in the AQAA that no referrals have been made under safeguarding protocols. They had reviewed and signed the adult protection policy and procedure, which was readily available. This clearly identified for staff the actions they should take to report any concerns they had. It also identified actions for the manager to take in line with the local multidisciplinary protocols and guidance. A copy of Essex County Councils safeguarding adults training pack was available which the manager stated was used as part of staff induction. This was confirmed by staff spoken with who were also able to identify various types of abuse and appropriate reporting and whistleblowing actions that they would take. Staff induction and training files sampled confirmed that staff had had training on safeguarding vulnerable people. A concern regarding safe recruitment procedures is considered under the heading Staffing. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect a pleasant living environment that promotes independence, however additional risk assessments would better ensure their safety and well-being. Evidence: The Seton Unit provides residents with a large and pleasant lounge/dining room. Patio doors lead on to a roof garden/sun terrace where residents can sit to enjoy the views over the grounds or tend to the plants. The manager confirmed that she would undertake a risk assessment without delay to ensure the safety and well-being of residents using this area. A small kitchen is available where residents can make snacks and drinks if they choose, so promoting choice and independence. Evidence from resident meetings and Regulation 26 reports showed that arrangements are being made to provide a washing machine on the Unit for residents who may wish to use it. All residents have their own bedroom, which are personalised, ensuite and fitted with door locks to promote privacy and dignity. A separate bathroom with assisted facilities was available and there was evidence that, following resident suggestion, consideration is being given to providing an accessible shower facility. New windows had been fitted in most areas. However, the sash windows on the corridor and bathroom need to be risk assessed as they are not restricted, so the manager can ensure the safety and well-being of all residents at Seton Unit. Care Homes for Older People Page 20 of 29 Evidence: Inspection of records indicated that there had been several occasions where the lift had broken down, although the commission had not been notified as required. Planned maintenance is imminent and the manager confirmed additional support would be provided to any resident who needed to use the stairs in the interim. Residents will be able to access the chapel tribune from the Seton Unit during this time. The premises was clean and free from odours. Staff spoken with confirmed that they had access to appropriate protective equipment, for example gloves and aprons. They were able to demonstrate appropriate infection control measures for example in relation to laundry. Surveys received from residents confirmed that the home is always fresh and clean and one person commented each room is cleaned every day. Residents spoken with confirmed they were satisfied with the facilities provided. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to be supported by competent staff in adequate numbers to meet their needs but they may not be best safeguarded by the current recruitment procedures. Evidence: Staff turnover is low and many of the staff have worked at the Seton Unit for years. Discussion with staff and inspection of the rotas show the current staffing levels to be two care staff throughout the day and one staff at night, although additional support can be accessed from the Marillac care home. Staff and residents spoken with confirmed that this is adequate and a resident said the staff are available when needed. This was also confirmed in the resident surveys received with one comment a very caring and supportive staff work here and they are always ready to help and support me. A housekeeper is on duty five mornings a week and meals are prepared by staff in the Marillac. In the AQAA the manager confirmed that 50 of the permanent staff have achieved or are working towards NVQ level 2 or above. Two staff spoken with confirmed that they had achieved NVQ level 3. A recruitment file reviewed contained timely references, appropriate identification Care Homes for Older People Page 22 of 29 Evidence: supported by a current photograph, a declaration of health and offences and a statement of terms and conditions of employment. The application format requested a five-year employment history. This does not comply with Regulation which requires a full employment history to be provided. There was no evidence of Povafirst or apprpriate criminal record bureau check. The registered manager advised that they had questioned this but were informed by their human resources department that it was suitable as the prospective staff member was employed by another registered service. The manager subsequently confirmed that they would ensure that these checks were undertaken immediately and appropriate steps taken to safeguard residents in the interim. Two staff development files reviewed confirm the information in the AQAA of an appropriate induction programme, currently based on the Common Induction Standards. This was supported by training records which confirmed that staff had attended training in issues such as medication, fire, dementia awareness, protecting vulnerable people, Parkinsons disease, food safety awareness, falls prevention and the mental capacity act. One file contained evidence of recent moving and handling training while the other certificates was some years old. The manager advised that all staff receive an annual update in moving and handling training, accessed through the training available in the Marillac. Staff spoken with confirmed they had recently undertaken updated training in moving and handling and have regular access to training. They also spoke of good working relationships and communication in the staff team with a handover each shift to support this. One staff member said they believed they gave residents excellent care and choice. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is generally effectively managed and is run in their best interests. Evidence: The manager has applied for and successfully been registered since the last inspection. The manager advised that they have redone all mandatory training since being at Seton Unit and have also recently undertaken training in the mental capacity act and the deprivation of liberty safeguards. In response to this, they plan to display the numbers for the keypads that allow access from the premises, although these are already known to all the current residents. In their AQAA, the manager identifies that they need to continue to work with staff to improve standards of documentation. This should also be carried through into other areas of documentation including staff recruitment files and sending appropriate notifications to the commission. Care Homes for Older People Page 24 of 29 Evidence: Staff and residents spoken with confirmed that the manager is approachable and supportive and one resident said be good to (manager) because she is good to us. Evidence was available to show that residents views are sought through surveys and the information from this had been collated and fed back. Visitors had also been surveyed and comments noted included I was most impressed by the quality of the staff-most caring and attentive and it is always a joy to visit my (relative) in Seton Unit and find them so happy and well cared for by an excellent team of people. Residents confirmed they can express their views in the regular resident meetings. Issues raised by residents in these meetings were noted to be followed through in the available reports of the monthly required Regulation 26 visits. However, the reports for several months were not available although the registered manager stated that visits had been undertaken routinely. Money is looked after for some residents and securely stored in the safe, with individual wallets and individual records. The manager advised that residents personal allowance comes to them in an individual envelope from the Finance office. Residents sign for whatever amounts they wish to withdraw and this is also signed for by the person handing over the money. Receipts are therefore only available for items that the manager may order for residents to support them, for example this was seen for a pair of shoes. Records and money remaining in wallets sampled were found to tally. Records of two recent supervisions were seen on each of the staff files reviewed and were appropriate in format. The registered manager advised that this is an area they know they need to improve on to ensure that it occurs at least six times annually for all staff. A record was seen of a recent group supervision session that was used to feedback to staff the outcome of the quality assurance exercise and to discuss this. Aspects of health and safety were reviewed and found to be satisfactory. Minutes were available to evidence that health and safety meetings occur regularly. Safe working practice risk assessments were available and in date, as were coshh data sheets and risk assessments. Current inspection certificates were available relating to the hoist, fire alarm, emergency lighting, fire extinguishers and gas. The current certificate of employers liability was available. Fire drills recorded the name of the staff who attended and it was noted positively that recent fire drills had been under for staff on night duty. Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 29 17 (3) (b) Recruitment records required 05/01/2007 by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and accurate and be easily available and accessible for inspection and emergencies at all times. This also with reference to other staff records such as training and supervision files. Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 13 Ensure that the roof terrace and opening sash windows are assessed and any unnecessary risks eliminated. To ensure the safety and well-being of residents 12/11/2008 2 29 19 All required information, 30/10/2008 references and checks must be in place for prospective staff members prior to employment. This includes a full employment history and appropriate Povafirst and criminal records bureau checks. To safeguard residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 Preadmission assessment documents should contain opportunity to record the date and the signatures of both the assessor and the prospective resident. Page 27 of 29 Care Homes for Older People 2 7 Ensure that risk assessment such as those for moving and handling are dated, to evidence that they are current, relevant to the person and regularly reviewed. Ensure that all medications administered, or if not administered the reasons why, are recorded to ensure that residents always receive their medications as prescribed. Continue to develop the plan to fit an accessible shower so that residents preferences are met. To show regular access to training for all staff to support them to meet residents needs, evidence of training should be maintained on staff development files for inspection. The manager should ensure that they send all notifications to the commission required by regulation, this includes each time the lift breaks down. Reports should be available to evidence monthly visits to the home by the responsible individual to assess its conduct. 3 9 4 5 21 30 6 32 7 33 Care Homes for Older People Page 28 of 29 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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