Inspection on 30/05/07 for Somerleigh Court

This inspection was carried out on 30th May 2007.

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

Somerleigh Court 29/10/07

Somerleigh Court 16/08/06

Somerleigh Court 27/10/05

Somerleigh Court 07/04/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Somerleigh Court Somerleigh Road Dorchester Dorset DT1 1AQ Lead Inspector Gloria Ashwell Key Unannounced Inspection 30th May 2007 12:15 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 DS0000062046.V341319.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. DS0000062046.V341319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somerleigh Court Address Somerleigh Road Dorchester Dorset DT1 1AQ 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) 01305 259 882 01305 259 883 robinwaterer@bentleighcross.co.uk Bentleigh Care Ltd Post Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (25) of places DS0000062046.V341319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 15 service users under the category of DE(E) to be accommodated on the top floor of the building. Two named persons (as known to the CSCI) between the ages of 6065 may be accommodated to receive care. Two persons requiring palliative nursing care may be accommodated. Date of last inspection 16th August 2006 Brief Description of the Service: Somerleigh Court is a purpose built nursing care home, first registered during November 2004. It is located close to the centre of Dorchester, within walking distance of shops and other facilities including a GP practice. Resident accommodation is on the ground, first and second floors; each floor comprises a separate unit with a dedicated staff team, lounge/dining room, kitchenette and hygiene facilities (including assisted bathing facilities to aid safe movement of service users with impaired mobility). The second (top) floor is registered to accommodate a maximum of 15 elderly persons requiring nursing care for conditions associated with dementia; the ground and first floors are registered to accommodate up to 25 elderly persons requiring nursing care. At all times a registered nurse is on duty on each unit. All residents are accommodated in single bedrooms with en suite toilets and wash hand basins. Visitors’ cars may be parked close to the home (a permit obtained from the home MUST be displayed). Laundering of clothing and household linen is carried out at the home and arrangements are made for chiropodists, opticians and other health and social care professionals to visit individual residents. Fees are charged weekly; at present fees for permanent residents range between £735 and £800 per person. DS0000062046.V341319.R01.S.doc Version 5.2 Page 5 Information regarding the subjects Value for Money and Fair Terms in Contracts can be obtained from the web link: www.oft.gov.uk A report entitled Care Homes in the UK - A Market Study is available on web link http:/www.oft.gov.uk/NR/rdonlyres/5362CA9D-764D-4636-A4B1-A65A7AFD347B/0/oft780.pdf DS0000062046.V341319.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key announced inspection that took place at the home over two days, comprising a total of seven hours. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a plan for the inspection visit. The inspector arrived at 12.15 on 30 May 2007 and spoke to residents and staff and toured the premises. By arrangement with the acting manager, she returned to the home at 10.00 on 9 June 2007 and assisted by the acting manager discussed and examined documentation relating to the care provision and administration of the home. The care records of four people who live at the home were examined in detail. The inspector was able to meet and speak with most of the residents both individually and in small groups in the communal areas. Additional information used to inform the inspection process included the reports routinely sent to the Commission by the Registered Provider. Since the previous key inspection a random inspection took place during October 2006 to monitor progress on meeting the medicine handling requirements identified in the report of the key inspection; with one exception all were met. The last was found met at this inspection. What the service does well: People considering moving into Somerleigh Court receive a full assessment and are provided with the opportunity to visit and spend time at the home to make sure that it is able to meet their needs. Somerleigh Court provides a calm, tranquil and peaceful environment to elderly people requiring nursing care, including (on the top floor) those experiencing the confusion of dementia and similar mental health circumstances. On the days of inspection the home was very clean, of comfortable temperature and adequately staffed. The home is well equipped, attractively decorated and suitably furnished. The standard of general nursing care is good. Residents are generally satisfied with Somerleigh Court; one said of the staff “They’re all very kind and that is so important”. DS0000062046.V341319.R01.S.doc Version 5.2 Page 7 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. DS0000062046.V341319.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000062046.V341319.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide Intermediate Care so Standard 6 does not apply. The Statement of Purpose does not give clear relevant information about the home so is unlikely to provide prospective residents and their representatives with an accurate understanding of the people for whom the service is intended. The service user guide is not provided in formats alternative to a standard typed document, so may not be appropriate to the needs and capacity of individual prospective residents or their representatives; they might find it difficult to read and fully understand. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them. DS0000062046.V341319.R01.S.doc Version 5.2 Page 10 EVIDENCE: The service user guide is made available to all residents and prospective residents. It contains general information about the home including the replies made to a user satisfaction questionnaire issued during January 2007; however it does not provide information on actions taken or planned to improve the questionnaire replies that indicated some weaknesses of the service. The Statement of Purpose and service user guide are available in a standard format; no other format is available and consideration should be given to provision of this information in alternative formats. The Statement of Purpose does not fully describe the service and the people for whom it is intended; in particular, it omits reference to the current ‘conditions of registration’ stated in the introductory pages of this report prospective service users may thereby not have sufficient information upon which to base their decision to enter the home. The records of a recently admitted resident included details of pre-admission assessment carried out by a trained nurse who visited the person in hospital. The assessment records identified the needs of the prospective resident and enabled the staff to determine that the home would be able to properly meet them. Close relatives of the prospective resident visited Somerleigh Court to meet the staff and view the accommodation, on behalf of the prospective resident who was too frail to do this in person. The inspector spoke to the resident who confirmed satisfaction with the home. The inspector spoke to the particular resident for the purposes of case tracking; unreserved satisfaction with all aspects of the home was indicated. DS0000062046.V341319.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of nursing care is good but improvements must be made to care documentation to ensure that staff have sufficient information upon which to base their care practice and to ensure that residents are all treated with respect and their rights are upheld. Medicines prescribed by doctors are safely stored and correctly administered. EVIDENCE: Residents believe they are properly cared for but there was evidence that their rights and dignity are not routinely met. One resident said he is not allowed to go outside alone although he would like to do so; discussion with the acting manager and examination of care records confirmed that staff felt they were acting in this person’s best interests by minimising risks of accident, but had DS0000062046.V341319.R01.S.doc Version 5.2 Page 12 not discussed this with him or his representatives and had not adequately documented a risk assessment and associated care practice. Accident and care records indicated that a resident who does not like being bathed and is frequently physically resistive to this act is nonetheless routinely bathed, and has on such occasions been physically aggressive and injured staff. Records of care for this person contained insufficient guidance for staff, the accidents/incidents of physical aggression had not been investigated and adequately recorded and in discussion the acting manager failed to demonstrate sufficient understanding of the involved aspects of ‘adult protection’. As noted in the report of the previous inspection, some care records were vague e.g. “aggressive” without stating in what way the person was behaving and why this was happening. Care records of 4 other residents were examined and found to contain risk assessments forming the basis for care plans and daily records describing the care of each person. The records of a person who had recently died in the home were examined and indicated that a very good standard of nursing and pain management had been provided. However, there was insufficient evidence that individual residents or their representatives had been involved in the development and review of planned care provision. It is required that all care plans and other care records be improved to ensure provision of accurate information to staff to enable them to properly care for every resident. Medicine handling is carried out by registered nurses and medication administration records were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts. Residents wishing to do so can manage their own medicines; at present none have chosen to do so. Urgent improvements must be made to ensure that the rights, freedoms and dignity of each resident are properly promoted, and they are treated with respect at all times. DS0000062046.V341319.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 adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide a service that is sufficiently flexible to the varying needs of the residents; social and recreational activities are infrequent and are not suited to the preferences and abilities of all residents and there is minimal choice for meals with little evidence of ‘good practice’ with particular regard to the needs and abilities of individual residents. EVIDENCE: Recreational and social activities are provided infrequently and are not suited to the abilities and preferences of all residents; some residents are not satisfied with these aspects of the lifestyle offered by the service. Staff are employed to arrange activities but are insufficiently trained to be able to carry out this work to meet the differing needs and abilities of the residents. A care worker is employed for 24 hours each week to arrange activities on the DS0000062046.V341319.R01.S.doc Version 5.2 Page 14 top floor, and for the ground and first floor care workers are employed for 6 ¼ hours and 8 hours per week, respectively. Examination of the activity programme displayed on the ground floor indicated that activities should take place on two days each week during June 2007, but for 2 of the 4 weeks the activity organiser would be on holiday, so no alternative arrangements had been made. The newsletter that had been produced during the previous year was discontinued after the first couple of issues. A very basic replacement has been recently made but provides little information to relatives and comprises mainly cartoons and crosswords copied from newspapers. Residents able to express an opinion said the activities are infrequent and when they do take place often fail to interest them. The residents indicated that visits by their friends and relatives provide most of their social interaction. There is a ‘close care’ apartment suite which when not in use in this capacity is occasionally available to accommodate the relatives of residents who live a long distance from the home. Meals provide adequate nutrition but residents have very little choice, menus are not displayed and the good practice of provision of daily ‘finger food’ to residents with special needs introduced as a result of the previous inspection has been largely discontinued. A resident described the meals as being like “ old fashioned school meals….nothing fancy” and observed that greater variety and choice would be appreciated. DS0000062046.V341319.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaints procedure provides information on the procedure to follow to persons wishing to make complaint; all complaints are recorded and investigated. Measures to safeguard residents from risks of abuse are unreliable and insufficient. EVIDENCE: During April 2007 a written complaint was made to the home regarding the prolonged unreliability of the system for providing hot water, with particular regard to the washing and bathing of residents. During the inspection the home was unable to supply evidence that a reply had been made to the complainant but on 12 July 2007 sent to the Commission the related documentation confirming they had investigated and a written reply had been sent to the complainant. No further issues have been raised concerning this matter by the resident or relative and the problem has been satisfactorily resolved. DS0000062046.V341319.R01.S.doc Version 5.2 Page 16 The policy/procedure for safeguarding adults is unclear and fails to provide staff with clear and comprehensive information about the various forms abuse may take. A sample of staff induction and training records were examined and indicated that a number of staff (including one person employed since 2005) have not received training in the understanding and prevention of abuse. As described for Standard 8 of this report there was evidence of poor practice, with indications that all residents are not properly protected from risks of abuse. DS0000062046.V341319.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, 21 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Somerleigh Court is a well-appointed and comfortable home. On the days of inspection the home was clean, pleasant and hygienic but there was evidence indicating that during recent months residents have been discomforted by the unreliable hot water system and that there are concerns regarding the heating of some parts of residents accommodation. The home has been slow to correct the hot water problem and appears to have taken no action with regard to the heating concern. DS0000062046.V341319.R01.S.doc Version 5.2 Page 18 EVIDENCE: Somerleigh Court is an attractive home, with good-sized bedrooms, bathrooms equipped for the use of persons requiring assistance and attractive communal rooms. The home is clean, tidy and comfortable throughout; there were no unpleasant odours. The home is well equipped; all residents have profiling beds which can be adjusted to height and shape e.g. head end raised, foot end raised. All areas of resident accommodation are accessible to wheelchair users; there is a passenger lift and no necessity to negotiate steps or stairs. However, since late January 2007 there have been problems regarding the provision of hot water to residents bedrooms and bathrooms. The problem was notified to the inspector on 10 April 2007 and later that month was the subject of the complaint referred to for Standard 16 of this report. The letter of complaint noted that for the “past few months staff…have to ferry bowls of hot water to Xs room each day….baths are irregular….(X has been) without a bath for 2 weeks or more…”. The problem was discussed on the first day of this inspection, and on the concluding day the water supplied to a bath was checked and found to be sufficiently warm; the staff running the bath water confirmed that throughout that morning, and for the first time in months, there was an adequate supply of hot water throughout the building. A specialist plumber had attended the home on the previous day and had successfully resolved the problem. During the tour of the premises a visiting relative observed that there is no form of heating provided to the en suite hygiene facilities of bedrooms; the provision of warmth to the en suite facilities is reliant upon warmth spreading from the bedroom when the door is left ajar. The same circumstance was brought to the home’s attention in the satisfaction questionnaire completed during January 2007, but there was no evidence that consideration for improvement has been given to this matter. DS0000062046.V341319.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. Staff do not reliably receive training in essential subjects at the desired frequencies. EVIDENCE: At the time of inspection there were sufficient staff on duty to properly meet the needs of residents and residents stated they think there are usually enough staff. A concern regarding the hours worked by a member of night staff was made known to the Commission during late April 2007; the content of the concern DS0000062046.V341319.R01.S.doc Version 5.2 Page 20 was forwarded to the home for investigation and the reply is at present awaited by the inspector. The records of two staff employed since the previous inspection were examined and confirmed they had undergone appropriate recruitment procedures including provision of Criminal Records Bureau checks and written references. Residents are not involved in the recruitment of staff. Examination of a sample of staff training records indicated that training in essential subjects was not reliably provided at the desired frequency. A trained nurse has received no training in moving and handling since an unspecified date in 2005 and although routinely involved in the serving of food had not received training in food hygiene A care worker observed serving food to residents had not received food hygiene training, and neither of these staff had received training in ‘adult protection’. The recorded dates of training which had been provided were invariably imprecise, stating only the year in which the training had taken place. However, most care staff have obtained a National Vocational Qualification in care; the home thereby meets the standard for at least 50 of the care staff to hold an NVQ in care. DS0000062046.V341319.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 adequate. This judgement has been made using available evidence including a visit to this service. The provider organisation has recognised the current weaknesses in service provision and has appointed a consultant to oversee necessary improvements, designed to provide a more ‘user focussed’ environment better suited to the needs of residents. Improvements must be made to ensure the proper protection of residents. DS0000062046.V341319.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the previous key inspection the registered manager has left the homes’ employ; Somerleigh Court is at present in the day to day charge of a trained nurse in the role of acting manager, working with the support and supervision of a consultant (also a trained nurse) who has been recently engaged specifically for this purpose by the registered provider. The acting manager is used to working in the home as the ‘head of care’ and demonstrates competency in this work, but is unused to being the manager, was unaware of many recent developments in the regulatory and inspection process and in consequence experienced difficulties during this inspection. There are significant weaknesses in staff induction and training and there is no system for the formal supervision of staff. The systems for quality assurance are inadequate; a user satisfaction survey based on questionnaires was conducted during January 2007. Responses indicated many instances of perceived weakness, where improvements were necessary, but no further work has been done in this regard. Many of the areas identified for improvement in the completed questionnaires are the same as those identified by this inspection e.g. activities, involvement in care planning, heating of en suite facilities. No meetings for residents or relatives have taken place during 2007. The report of the previous inspection referred to problems regarding the home’s telephone answering which appear unimproved; the inspector telephoned the home at approximate 2pm on a Friday afternoon in May of this year – the line was connected to an answering machine. The inspector left a message requesting her call be returned later that day – it was never returned. Relatives made similar observations during their discussions with the inspector. The home does not manage the finances of residents; residents who are unable to undertake this responsibility personally have nominated relatives, friends or other representatives to do this on their behalf. Records are kept of accidents and these are periodically audited but as in the report of the previous inspection it is recommended that the records be expanded to include details of investigation. Staff trained in First Aid and health care are on duty in the home at all times. Examination of records indicated that staff receive training in fire safety at the required frequencies, and arrangements for the periodic checking of fire alarms and emergency lighting are satisfactory. DS0000062046.V341319.R01.S.doc Version 5.2 Page 23 However, the newly appointed consultant has identified many instances of overdue safety checks e.g. there had been no evidence of the checking of bed rails and fire safety equipment, and has promptly instigated the necessary actions. The consultant is carrying out a thorough review of the service and on behalf of the registered provider is carrying out monthly visits and recording the findings of these visits. DS0000062046.V341319.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 DS0000062046.V341319.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1) also 6 Requirement The Statement of Purpose and service user guide must be improved to provide prospective service users with sufficient information to enable them to make an informed choice regarding admission to the home. The necessary improvements to care records must be made to ensure that each resident’s health, personal and social needs are accurately documented and kept under review. Residents must be treated with respect and their rights must be upheld. The service must make arrangements to ensure that residents are protected from abuse, in its various forms. The lifestyle of the home must be able to satisfy the interests and needs of the individual residents. The complaints policy and procedure must be properly followed, to include records of investigation and reply. DS0000062046.V341319.R01.S.doc Timescale for action 01/10/07 2. OP7 15 01/08/07 3. OP10 OP18 13 01/07/07 4. OP12 16 (2)(m) 01/10/07 5. OP16 22 01/07/07 Version 5.2 Page 26 6. OP31 8 Application must be made to the Commission by a suitable person for registration as manager of the service. 01/10/07 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. 5. 6. 7. Refer to Standard OP1 OP7 OP15 OP18 OP25 OP30 OP33 Good Practice Recommendations The statement of purpose and service user guide should be made available in alternative formats. Residents and/or their representatives should be involved in the development and periodic review of the care plan. Food should be provided to each resident in a manner suited to individual need and preference. All staff involved in food handling should receive training in food hygiene. The policy and procedure for safeguarding adults should provide clear guidance to staff, who should all receive related training. Consideration should be afforded to the provision of heating the en suite hygiene facilities of bedrooms. Records of staff training should reliably state the dates on which training in essential subjects has been received. There should be effective quality assurance and quality monitoring systems, ensuring that the home is run in the best interests of service users. DS0000062046.V341319.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000062046.V341319.R01.S.doc Version 5.2 Page 28 - 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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