Inspection on 03/01/07 for Shiels Court

This inspection was carried out on 3rd January 2007.

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.

Other inspections for this house

Shiels Court 28/08/09

Shiels Court 22/10/07

Shiels Court 19/12/05

Shiels Court 24/08/05

Shiels Court 18/05/05

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 Shiels Court Braydeston Avenue Brundall Norwich Norfolk NR13 5JX Lead Inspector Hilary Shephard Unannounced Inspection 3rd January 2007 08:35 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 Shiels Court DS0000063180.V325938.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. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shiels Court Address Braydeston Avenue Brundall Norwich Norfolk NR13 5JX 01603 712029 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) shiels@broadgate-healthcare.co.uk shiels@broadgate-healthcare.co.uk Mr M Afsar Mrs Susan Jane Brooksby Care Home 40 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (40), Old age, not falling within any other of places category (3) Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One (1) Service User under the age of 65 may be accommodated. Three older people whose names are held on the Commission`s records, who do not have dementia, may be accommodated. Once these service users have left the home the registration will revert to 40 older people with dementia. 19th December 2005 Date of last inspection Brief Description of the Service: Shiels Court is a large Victorian house situated in the village of Brundall. The original house has been altered and extended over the years and now provides care and accommodation for up to 40 older people with dementia. The bedroom accommodation for residents is on three floors and consists of 26 single and 7 shared bedrooms (all with en suite WC). The communal space consists of one very large lounge with a partition across separating the dining room, a separate smaller lounge and at the rear of the building a further small lounge, which is often used by staff for training purposes, and by visitors as an area to meet residents in private. The home also has extensive gardens currently being altered to meet the needs of the residents. The home informed CSCI of its charges in August 2006 and charges the following for care provision: from £423 to £433 per week. Residents are expected to pay extra for hairdressing, chiropody newspapers, magazines, manicures and hand massage. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgments for each outcome group. A total of 5 requirements and 1 recommendation were made as a result of this inspection. The Commission had serious concerns about the home in 2004, however visits to the home in 2005 found considerable improvements made to care practice and the premises since the new owners took over in March 2005. What the service does well: Prospective residents are assessed before admission and are provided with enough information to enable a proper choice to be made about moving into the home. The food is good, plentiful and home made from fresh ingredients. Residents generally enjoy their lifestyle. Staffing levels are sufficient to meet the residents current needs and staff are competent and are provided with plenty of training opportunities to help them give the correct care to the residents. The home is well managed by a competent and qualified manager. There is a good management and staffing structure in place to provide residents with a good team of staff. The manager is proactive and forward thinking and ensures the quality of the service provided to residents is regularly monitored and improved as needed. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 6 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. Shiels Court DS0000063180.V325938.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 Shiels Court DS0000063180.V325938.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 and 3 Quality in this outcome area is good. Residents’ needs are assessed before admission and the information is used as part of their care planning. Residents are provided with information before admission to enable them to make a choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Previous visits to the home have found that the manager visited prospective residents and completed a full assessment of their needs. The assessment was then used to form the basis of their care plan. The January 07 visit found this continues to be the case. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 9 At the January 07 visit, the manager explained she was updating the service user guide to include photographs they would show to prospective residents. A survey carried out by CSCI in August 06 with relatives of residents in the home shows that 57 (4 of 7) of residents had received a contract and 71 (5 of 7) of residents said they had received enough information to enable them to make a decision about moving into the home. Shiels Court DS0000063180.V325938.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. The outcome of this group of standards could be good or excellent if the home made sure care was provided in a person focussed way that embraces valuing residents as individuals in a way that looks at the care they need from their perspective in surroundings that are enabling and supportive. This judgement has been made using available evidence including a visit to this service. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 11 EVIDENCE: A previous visit carried out in December 05 found care plans continued to improve, some contained information about residents social and emotional care needs and a life history but information recorded was brief and not always referred to in the guidelines for staff to follow. Other general care needs had been identified, but the guidelines for staff to follow were omitted. Some care plans were more focussed on the residents’ individual needs and abilities than others. The January 07 visit found care plans continue to improve and the manager has changed and improved the format in some of them and plans to change them all over the next few months. It is disappointing to note that the care planning standard has never been completely met since the introduction of the National Minimum Standards. Care plans now contain more information about residents life history which in some is reflected in the care planning, however, information gathered during the initial assessment about residents hobbies and interests is not being included in the care planning for meeting residents social needs. Care plans have risks assessments about residents nutritional needs and some care plans contained information about residents weight. Some residents have problems with eating but there was no care plan to give staff instruction about how they should be helping those residents. Care plans included assessments about residents’ pressure areas but where residents were assessed as being at a high risk of developing pressure sores there was no care plan for the management of this. The manager advised that care plans for pressure area care were to be introduced shortly and none of the residents have pressure sores at the present time. Care plans need to be more focussed in ways that look at the residents needs from their perspective. One care plan identified a problem with incontinence but failed to look at this from the residents perspective, stating the resident should be offered the use of the toilet as per the toileting regime without providing guidance in how this was to be done. Comments received from residents and relatives in the recent CSCI survey indicate that 71 felt they received the medical support they needed, 42 felt they always received the care and support they needed and 57 said they usually do. Relatives commented “whenever we visit or phone, the staff immediately respond to our questions or requests”. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 12 Observations showed residents being treated with respect but during mealtimes plastic cups were provided to the majority of residents and drinks were all pre-poured. In the smaller lounge/dining room, more able bodied residents were provided with tea in a pot and glasses with their meals. Their tables were properly laid. The Commissions specialist Pharmacist Inspector reviewed the medication on 7th December 05 and found that the management of medicines had improved considerably since the previous inspection. Some recording and administration errors were noted at that visit and 2 requirements were made. Medication was inspected at the January 07 visit and found that the recording of medication given was good with one exception where gaps were noted on one medication administration records (MAR) chart. Senior care staff confirmed that medicines are regularly audited and any discrepancies are quickly remedied. The fridge used to store medicines was not having its temperature monitored, which was a requirement from the Dec 05 visit. Requirements have been repeated regarding care planning and medication and a recommendation made regarding person centred care. Shiels Court DS0000063180.V325938.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. The lifestyle experienced by the residents is generally positive and enjoyable, family contact is encouraged and maintained. Meals are well prepared and nicely presented. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The December 05 visit found residents were quite happy and settled. The manager had reviewed the activities provided in the home and introduced new ones for the residents to participate in. Staff were seen to be interacting well with residents throughout that visit. The January 07 visit found this continued to be the case, but staff said they were busier and had less time to spend with residents. However, the manager had arranged for some staff to receive training in reminiscence therapy and a group was underway during the afternoon with staff and residents. One staff was spoken with about the types of activity and occupation provided for residents and explained how the key workers do this according to residents needs. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 14 Comments from residents and relatives from the recent CSCI survey indicate they have mixed views about the activities provided. 29 said there were always activities they could participate in, 14 said usually, 43 said sometimes and 14 said never. They also made comments such as: “Birthdays are celebrated for the residents with their relatives” “My mother has been out for coach trips” “More use of the garden would be advantageous” More plants and shrubs would be interesting to the residents” “Books, magazines and newspapers might be stimulating to some residents” “My Aunt loves the minibus outings, she is very fond of music too”. The December 05 visit found residents happy that they were able to make choices about their lifestyle but said they were not able to choose their meals. The January 07 visit found this continued to be the case. The manager had introduced and tried different ways of giving residents choices about meals but was having difficulty making this work. The home has tried showing residents two different plated meals and photographs of meals but neither method worked very well. Staff now try to ask residents in the morning what they would like for lunch and display the menu choices on a notice board near the lounge, but find the residents do not remember what they have chosen. Choice of drink at lunchtime was not offered and residents were not given the opportunity to pour drinks themselves or have drinks at times other than the regular tea and coffee rounds. Staff were very willing to give residents drinks when asked for, but most of the residents were not able to ask. Care plans showed residents were not being enabled to choose their preferred time, day or amount of baths or showers they would like and staff were using a bath rota book rather than finding out residents preferred bathing habits. This shows the home has not fully developed a person centred ethos. Lunch was taken with the residents during the January 07 visit and was good. Residents enjoyed their meal and said the food is good, there was plenty available and residents were asked if they wanted second helpings. Meals are prepared from fresh, tinned and frozen ingredients and the home usually uses local suppliers. A varied buffet style tea is provided which looked interesting and tasty and the manager explained how she has changed the meal times to reduce the length of time between tea and breakfast. She says this has meant that residents have put weight on and are more settled at night. Staff assisted those that needed help gently and discreetly. Shiels Court DS0000063180.V325938.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 and 18 Quality in this outcome area is good. The home has a complaints procedure but not all residents are aware of whom to go to with their concerns. The home makes every effort to protect residents from harm and staff understand about reporting issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A previous visit in May 05 found that the home had received two complaints. Although one complaint had been referred to the Commission, the manager had already put measures in place to resolve the issues raised. The manager dealt with the second complaint to the complainants satisfaction. Comments received from residents and relatives indicate 50 of relatives knew how to make a complaint and 50 did not. 57 of residents knew who to speak to if they were unhappy and 57 said they knew how to make a complaint. One comment from a relative stated “I have spoken out on (name) behalf when I have perceived a problem and the staff have taken action where possible”. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 16 One concern had been received by the Commission in August 06 and was referred to the manager who addressed the issues immediately. No other concerns have been raised about the home since then. Staff continue to receive training in adult protection which is also included in their induction. Shiels Court DS0000063180.V325938.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 and 26 Quality in this outcome area is adequate. The outcome of this group of standards will be good once the home has completed the refurbishment, eradicated the unpleasant odours and improved the safety, signage, layout and design inside and out so it meets the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous visits carried out in May, August and December 2005 found considerable improvements made to the décor. Bedrooms were being refurbished and the proprietor planned a regular refurbishment programme. The downstairs ladies toilet had been improved and provided the residents with better privacy. All staff notices and equipment had been removed from resident areas. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 18 Information from the manager received in August 2006 indicates that since the last inspection, 14 bedrooms have been decorated, the ground, middle and top corridors have been redecorated, a new hoist, cooker, extractor, microwave, industrial washing machine and carpet cleaner have been purchased. New carpeting has been laid, handrails have been put up and doors have been replaced. New lighting is in the process of being installed. The January 07 visit found considerable improvements continue to be made with the décor. Many areas have been redecorated, new carpets have been laid, new care, catering and laundry equipment has been purchased. Some bedrooms have had floorboards replaced and new handrails have been fitted throughout all corridors. Changes have been made to the way the home is cleaned and it was clean at the time of this visit. However, two bedrooms smelled of urine and one smelled of damp and mould, the front entrance also smelled faintly of urine. The cleaning staff spoke of how they regularly clean the carpets but were having some difficulty eradicating odour in two of the bedrooms. The manager advised that the carpet is to be replaced in the entrance and the lounges and the rooms that had bad odours were a priority for refurbishment. Signage throughout the home was poor and the manager spoke of how she plans to improve this. Currently residents are not being guided by signage to find their bedrooms, toilets, lounge areas or dining rooms. Some en suite WCs are visible from the residents bed which is good as they are able to see it easily, however, some WC’s are all one colour and blend with the background making it difficult for people with dementia to see the toilet. The manager uses pressure mats linked to the call system for residents that like to get up in the night. The manager advised that refurbishments are continuing, the home will be rewired shortly, a new fire alarm and nurse call system will be installed in the next few months, new thermostats were to be fitted to all radiators and control valves to be fitted on all hot water taps. Requirements have not been made regarding the premises as the home is very clearly making improvements. The home has a large garden, which has been improved since the last visit. A fence has been erected all round and the trees at the back have been pruned to allow more light into the home. The manager advised further improvements are planned for the garden. A requirement has been made regarding odour. Shiels Court DS0000063180.V325938.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 good. Residents benefit from sufficient staffing levels, competent and trained staff and safe recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Visits carried out in May and August 2005 identified the home was not thoroughly vetting staff before employment. The December 2005 visit found significant improvements with this and staff were being properly vetted before they started work. The January 07 visit found the home continues to practice safe and thorough recruitment practices. Staffing levels have been increased over the past two years and are currently sufficient to meet the residents needs. The manager assesses staffing levels against the needs of the residents and increases these as required. There is always a senior carer on duty during the day and the manager or deputy provide on call cover. Staff spoke of how residents needs have changed and how they need a lot more support and assistance than previously. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 20 December 05 visit found out of 24 care staff employed at the home, 5 were working towards NVQ level 3 and 3 towards NVQ level 2. Information provided by the manager in January 2007 indicates there are 26 care staff employed and 4 have NVQ2 or above, two NVQ level 3 staff left the home in December 06. More NVQ training is due to commence in February 2007. Training opportunities for staff have improved significantly over the past two years. Staff now receive NVQ training and training specific to meet the residents needs. All staff receive thorough induction training. Senior staff spoke of receiving in depth medication administration training and assessment before they are allowed to administer medicines on their own. The manager assesses staffs training needs against the needs of the residents and provides relevant training. One staff spoke of a particular training need and the manager confirmed training had been arranged to cover that. The manager advised that some of the cleaning and care staff had taken on extra responsibilities regarding activity provision which residents were enjoying and this was seen to be the case during the morning of the visit. Shiels Court DS0000063180.V325938.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, 38 Quality in this outcome area is good. Residents benefit from living in a home that is well managed and well maintained by a competent manager. Some improvements are needed to the safety of the premises and the manager already has plans to address that. This judgement has been made using available evidence including a visit to this service. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has worked in the home since 2004 and was registered by the Commission in March 2006. She completed her Registered Managers Award in July 2006. The home is well managed and organised and staff morale, skills and competence have improved significantly in the past two years. Formal and informal quality monitoring is done on a regular basis and this has been an area of significant improvement over the past two years. The manager makes regular checks on the standards of cleanliness and maintenance throughout the building, assesses and monitored the service provided by care staff to residents and puts improvements into place as required. The manager undertook a recent survey with residents relatives but has not analysed or compiled a report of the findings. The manager is thinking of innovative ways to involve residents in formal quality monitoring as currently the majority of residents are unable to express a written opinion of how they think the home is being run. Residents finances were inspected during the January 07 visit. The home sometimes keeps small amounts of money for some residents, but the normal practice is for the home to pay for items and services and get reimbursed from the relatives. Written records and receipts are kept. The visit carried out in May 05 found the home was being managed safely and had made significant improvements to the safety of the environment, however the January 07 visit identified some areas where the home was not safe: • • • • • A cupboard storing chemicals and toiletries was left unlocked despite a notice saying to be kept locked. One double bedroom had an uncovered radiator, although was only warm to touch and did not pose an immediate risk to residents. The door leading from the entrance to the corridors was wedged and hooked open. Hot water temperatures are not individually controlled and the temperature is controlled at the boiler but were not hot enough to pose an immediate risk to residents. Some covered food had been left out in the kitchen without being refrigerated within recommended timescales. There were also unlabelled sandwiches for the residents tea that had not been placed in the fridge. Accident records are monitored and reviewed by the manager and evidence of this was seen on residents files. A requirement has been made regarding safety. Shiels Court DS0000063180.V325938.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 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Two 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 The Registered person must ensure that all care plans contain a life history, and provide full and detailed guidelines covering residents’ physical, social, emotional and psychological needs. Repeated, most recent deadline of 30/6/06 not met. The registered person must ensure that care plans contain details of how residents health and welfare needs are to be met, in particular needs relating to nutrition and pressure areas. The registered person must ensure the temperature of the medicine refrigerator is monitored and recorded on a daily basis. Repeated, deadline of 23/12/05 not met. The registered person must ensure the home is kept free from unpleasant odours. The registered person must ensure that unnecessary risk to the health or safety of residents are identified and so far as possible eliminated. DS0000063180.V325938.R01.S.doc Timescale for action 31/07/07 2 OP8 15 (1) 17 Schedule 3 (m) 13 (2) 31/07/07 3 OP9 31/03/07 4 5 OP26 OP38 16 (k) 13 (4, c) 31/07/07 31/03/07 Shiels Court Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP32 Good Practice Recommendations The registered person is recommenced to continue to research and develop a person focussed ethos within the home so that residents benefit from best practice in dementia care. Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Shiels Court DS0000063180.V325938.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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