CARE HOMES FOR OLDER PEOPLE
Speke Care Home 96-110 Eastern Avenue Liverpool Merseyside L24 2TB Lead Inspector
Mrs Trish Thomas Key Unannounced Inspection 3rd July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Speke Care Home DS0000025180.V340793.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. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Speke Care Home Address 96-110 Eastern Avenue Liverpool Merseyside L24 2TB 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) 0151 425 2137 spekecarehome@aol.com Mr Abid Y Chudary Mrs Chand Khurshid Latif Joan Lorraine Vernon Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53) of places Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th January 2007 Brief Description of the Service: Speke Care Home is registered with CSCI to provide care and support to 53 residents within the category of old age. This home was purpose built and is situated in a residential area in Speke, Merseyside. Speke Care Home is close to a range of local amenities including local shops. There are bus and road links to Liverpool and North Cheshire. Speke Care Home is a two-storey building with stair and passenger lift access. Bedrooms in one wing of the home have an en-suite toilet and wash hand-basin. There are lounges on the ground and first floor, a dining area and access to a secluded garden at rear with off road parking at the front of the building. Fees for the home have been listed at £315.50 per week and chiropody is included in this charge. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The visit to Speke Care Home was un-announced and took place over a sixhour period during which the service was assessed against National Minimum Standards. The methods used during the inspection were, discussion with twelve residents, two visitors, the manager, Mrs. Joan Vernon, and the staff who were on duty. The care plans of four residents were tracked and the personnel files for three staff members were read. Health & safety certificates, accident reports and training schedules were seen. A tour of the premises and grounds was carried out and a sample of quality questionnaires completed by residents, family and visiting health professions were read. What the service does well:
Residents and their visitors expressed satisfaction with the service. A resident said, “Staff are very polite and I could not fault them.” Another said, “The staff are great, they ask what you want and then get it for you.” A relative stated in a quality questionnaire dated April 2007, “I find the staff most helpful at all times, the kitchen staff do a wonderful job. All residents who live in Speke Care Home have had their needs assessed and have a care plan. Residents’ diversity is respected through supporting their religious beliefs and respecting and addressing their needs and choices. Residents looked well cared for and appeared relaxed. Some residents went out by taxi and with family. A bingo was arranged for those remaining at home who wished to take part, and others were reading or watching television in their bedrooms. The lifestyle in the home appeared to be meeting a range of needs and preferences. Residents said they were satisfied with their accommodation and their bedrooms were highly personalised, comfortable and clean. There is access from the main building, to the gardens where residents enjoy sitting out in fine weather. There is a low turnover of staff in Speke Care Home, and residents appear to be benefiting from the continuity of care provided. There are adequate levels of care and ancillary staff on duty to support the needs of residents. The manager, Mrs. Vernon has management qualifications and NVQ qualifications levels 2-4 have either been gained or are in progress for the majority of staff. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
To ensure that staff develop a broad knowledge of diversity issues in care giving, regarding race, gender, sexuality, age and culture, it is recommended that staff receive training in Equality and Diversity Some care plan reviews were out of date and to ensure that residents’ changing needs are identified and met, it is recommended that care plans be reviewed at least monthly. Some areas of the building are in need of decoration and refurbishment and the funds to carry out some of this work are available. To ensure that the accommodation is suitable for residents, it is recommended that the decoration and refurbishment programmes continue. Staff said they have had appraisals during the current year and to ensure that they are fully supported in fulfilling their roles and responsibilities, it is recommended that formal supervision (one to ones) be arranged for all staff every two months. The matters discussed should cover all aspects of practice in Speke Care Home, philosophy of care and development needs. Staff said that fire drills are carried out every week. To ensure that staff have the knowledge and skill to take action in case of fire, a recommendation is made that they receive fire instruction, three monthly for night staff and six monthly for day staff. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 7 The procedures in place for managing residents’ finances should protect residents and staff and ensure that all expenditure is accounted for and an up to date record of transactions maintained. A requirement is made that receipts are retained for purchases made on behalf of residents and records of personal allowances are maintained. To avoid the risk of injury to frail residents, the accident book needs to be monitored and risk assessments carried out for residents who are prone to falls and their care plans for mobility be updated. To ensure that residents are protected in case of fire and risks are identified and eliminated, contact with the Fire Authority should be made concerning the open space between smoking/non smoking areas. To avoid the risk of fire caused through residents who may be smoking without supervision, risk assessments are to be carried out for all residents who smoke. The double kitchen doors should be checked (by a qualified person) regarding gaps when closed on exiting, and remedial work should be carried out as necessary. This will be necessary to avoid the risk of ineffective fire doors. 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. Speke Care Home DS0000025180.V340793.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 Speke Care Home DS0000025180.V340793.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): Quality in this outcome area is good. People who are referred to Speke Care Home have had assessments carried out, to ensure that their needs can be met by the services and facilities on offer. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 3,4. Four care files, which were read, contained written assessments carried out before each person moved in to Speke Care Home. Social work assessments are carried out for those people who are referred through social services, and staff also carry out an assessment of each person’s needs, using a standardised format to record the outcomes. Pre-admission assessments are carried out to ensure that each person’s needs can be met within the skills and services on offer in Speke Care Home. The outcomes of assessments form the basis of each individual’s care plan. There was evidence in training schedules that staff have qualifications in care and receive ongoing updates in mandatory training. To ensure that staff
Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 10 develop a broad knowledge of diversity issues in care giving, regarding race, gender, sexuality, age and culture, a recommendation is made that staff receive training in Equality and Diversity. Speke Care Home DS0000025180.V340793.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): Quality in this outcome area is good. Residents’ needs have been assessed and care plans established to address their health and personal care, the process would be more effective if reviews were carried out more often. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7.8,9,10. All residents of Speke Care Home have a care plan and four care files were read to check that these were being used effectively. Residents’ diversity is respected in care giving through allocation of key workers (to ensure an individual approach), choice of rising and retiring times and support for maintaining independence through risk management. The care plans which were read, were in standardized format, with provision for action planning, managing risk and reviewing the process in accordance with the individual’s changing needs. Areas of support needs covered in care plans, include personal care, pressure care, continence, communication, mobility, diet and leisure. In some areas,
Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 12 reviews were out of date, some by three months. To ensure that residents’ changing needs are identified and met, a requirement is given that care plans are reviewed at least monthly. There was evidence in the files, which were read that residents have access to paramedical and health related services, such as chiropody, hospital appointments and district nurses. All those living permanently in Speke Care Home are registered with local G.P.s. The manager, Mrs. Joan Vernon, confirmed that there is very good support from the local doctors, and visits are arranged for residents on respite breaks who live outside the area if needed. Residents who commented said that the service provided in the home is good. One resident said, “I have all I need and only have to ask for what I want and I have it.” Speke Care Home has a procedure for staff to follow in the management of residents’ prescribed medication and all drugs are locked in a designated area. A senior care assistant explained the procedure followed for giving out, recording and auditing prescribed drugs. Those for four residents were checked, and were being managed to a satisfactory standard. There is a documented system in place for returning un-wanted medication to the pharmacy to ensure that there is an effective audit trail. At the time of this visit, there was a fairly large stock of non-prescribed homely remedies in store, such as cough medicines. A description of the procedure regarding non-prescribed drugs was requested. The member of staff confirmed that none of these drugs are given to residents without written authorisation from their G.P. She said records of authorisation are held on file with medical records for reference. Senior staff on duty said that they have received training in medication administration. Three residents said they receive their medication as prescribed and they had no cause for concern. One resident said he/she refuses to take any tablets, this was recorded on the MAR sheet and the G.P. had been informed. Residents said they are treated well by staff and their privacy is respected. Care staff were asked how they respect residents’ privacy and dignity and responses included, “By treating them as individuals.” “By ensuring that they are supported in private and making sure their records are secure.” A resident said, “Staff are very polite and I could not fault them.” Another said, “The staff are great, they ask what you want and then get it for you.” Speke Care Home DS0000025180.V340793.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): Quality in this outcome area is good. In respect for residents’ diversity the lifestyle in the home has been established to meet their expectations and wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,14,15. There is a monthly activities diary in Speke Care Home and the manager said she had recently ordered some equipment for various planned events. A snooker table is on order and a large screen television for the ground floor lounge. Residents were spending time in the lounges or in their bedrooms, one went out for lunch with family and another went out by taxi to visit friends. There is a pleasant lounge on the first floor with facilities for making drinks, which provide a private space for visitors and residents. Visitors to the home said they are made welcome and given privacy when calling in to see residents. Staff said there are no undue restrictions on visiting times saying, “Visits from family and friends are encouraged, residents look forward to their visits.” A relative stated in a quality questionnaire dated February 2007, “I feel at home when I visit my Mum. I can talk to staff at any time. It’s lovely.” Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 14 Residents’ diversity is respected through recording their religious beliefs on their care plans and making arrangements to support them. The manager said there are regular visits from local religious ministers and residents said their religious observances are supported. A relative stated in a quality questionnaire dated April 2007, “I find the staff most helpful at all times, the kitchen staff do a wonderful job.” The cook on duty confirmed that there is an allocated budget for food. There were good stocks of fresh (fruit, vegetables and meat), dry foods and frozen foods in store. There are written menus provided for residents, and these are seasonally reviewed. At the time of this visit, the kitchen was clean, well managed, and the equipment was in working order. Residents are offered a cooked breakfast, in addition to toast and cereals, a light lunch, main meal in the evening and a light supper. Hot and cold drinks are served regularly throughout the day or on request. Ten residents said the food is ample and well cooked and no person made negative comment. There was evidence of healthy eating plans being followed, in accordance with nutritional assessment and special diets, such as diabetic, being catered for. There is a qualified chef employed and support staff receive training in Basic Food Hygiene. The cook on duty said that kitchen staff are also offered the range of mandatory training courses which are undertaken by care staff. There is a pleasant and well-presented dining area on the ground floor and residents may have meals in their bedrooms or in the lounge, if this is what they prefer. Speke Care Home DS0000025180.V340793.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): Quality in this outcome area is adequate. There are procedures in place for residents’ protection but these were not stringent in protecting residents against the risk of financial abuse with regards to their personal allowances. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16,18. Speke Care Home has a complaints procedure, which is made available to residents and their representatives. The manager said that the last formal complaint was about five years ago. Speke Care Home has procedures for Protection of Vulnerable Adults and “Whistle-Blowing”. Training records and conversations with staff on duty gave evidence that staff have received training in Protection of Vulnerable Adults. There is a recruitment procedure, which includes the vetting of staff, Criminal Records Bureau Clearance and POVA checks. Records for managing residents’ personal allowances were seen and shortfalls in the process noted regarding lack of proof of purchase, (eg. retention of receipts of purchase, including those for cigarettes, made on residents’ behalf). To protect residents and staff and to ensure that all expenditure is accounted for and an up to date record of transactions maintained, a requirement is made under Regulation 13. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. The building is clean and generally well maintained and improvements to the environment are needed and have been planned. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19, 26. There are lounges on the ground and first floors, and dining area and residents’ smoking area on the ground floor. Residents’ bedrooms are for single occupancy and there is a double bedroom for any couple who may wish to share (subject to availability). There are bathrooms, en suites and toilets throughout the home for residents’ convenience, with assisted baths for those who are frail and need help while bathing. Some of the rooms need upgrading and there are plans to replace flooring / carpets and decorate some rooms, replace light fittings and fit an awning over the patio. Dining room chairs have been replaced and twelve bedrooms have been upgraded in recent months.
Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 17 Residents’ bedrooms are highly personalised and comfortable and have wash hand basins or en-suite facilities. One resident said, “I like my bedroom, it is warm and relaxing and there is room for a few pieces of my own furniture. It is good to have somewhere for visitors to sit. I cannot complain.” Some areas are in need of decoration/refurbishment, the funding is in place and the work has been scheduled. A recommendation is made that decoration and refurbishment programmes continue to be followed. There are procedures in place for the control of infection and management of substances hazardous to health. On a tour of the premises, the building was seen to be clean and odour free and housekeepers and laundry assistants are employed, who were following infection control procedures, which ensure a hygienic environment for residents. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There is a low turnover of staff and they receive training, which supports their roles and responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29, 30. The rosters were read and these gave a record of the staff numbers on duty in Speke Care Home, throughout the day and night. The manager said that there were no staff vacancies at the time of this visit and that all current staff are long-term employed. In addition to care staff and the manager, there are staff employed for cooking, laundry duties, housekeeping and administration. The manager’s hours are supernumerary to care staffing levels. Speke Care Home has a recruitment procedure, which was in evidence in the documents held in staff files. Those for three members of staff were read, they included CRB clearances and references and staff have been issued with job descriptions and contracts of employment. Over 50 of staff have care qualifications and training schedules give evidence of ongoing mandatory training/updates. A resident said, “All the staff are good at the job, I couldn’t find fault with them.” Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 19 Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Speke Care Home is well managed in general, but improvements are needed regarding fire safety and management of residents’ personal allowances. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 31,33,35, 36,38. Mrs. Vernon is the registered manager of Speke Care Home and she has management qualifications. Mrs. Vernon said that she follows an open-door style of management, which was confirmed by staff on duty. Mrs. Vernon displays a clear knowledge of residents’ needs and appears to have a good rapport with them. Speke Care Home has a Quality Assurance system, which is based on seeking the views of residents and visitors to the home. A sample of questionnaires for 2007, was read during the inspection, Two visitors who are health
Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 21 professionals gave “excellent- good” in feedback in questionnaires, and a relative stated, “My father is very happy and settled here. Staff are lovely.” Speke Care Home employs an administrator who co-ordinates fees and the personal allowances for seven of the residents. There is a clear record in place of the fees paid and personal allowance credits to individual residents. There was no running total of expenditure of personal allowances, and receipts had not been retained for purchases made by staff on behalf of residents. A requirement is made under Regulation 13, to ensure that there is an up to date account of personal allowances. Staff said they have not recently received formal supervision though they had appraisals in April 07. To ensure that staff are fully supported, a recommendation is made that one to one meetings be arranged with all staff to cover all aspects of practice, philosophy of care and development needs. Training schedules provide evidence that staff have received training in moving and handling and health and safety, and the servicing of equipment on the premises was in date. There are procedures in place for infection control and no cause for concern was observed regarding staff practice in these areas. A record of accidents to residents is maintained in the home. These records were discussed with the manager, regarding a resident who had fallen several times in recent weeks. Mrs. Vernon said that this person had since been discharged to another care home. To avoid the risk of injury to frail residents, the accident book should be monitored and risk assessments carried out for residents who are prone to falls and their care plans for mobility be updated. The fire safety log had been satisfactorily maintained. Although fire drills are carried out regularly, staff have not recently received fire safety instruction. To ensure that staff have the knowledge and skills to take action in case of fire, a recommendation is made that staff receive fire instruction, three monthly for night staff and six monthly for day staff). There is a residents’ smoking area adjacent to the lounge/dining room. There are no doors in place to divide smoking and non-smoking/eating areas. Mrs. Vernon said doors had been ordered. Mrs. Vernon also said she suspects that some of the residents may be smoking in their bedrooms though she has no clear evidence of this. To ensure that residents are protected in case of fire and risks are identified and eliminated, risk assessments should be carried out for residents who smoke. The double fire doors from the kitchen were not closing properly when exiting, leaving gaps which could render them ineffective in case of fire, these doors need to be checked by a qualified person and remedial work carried out as necessary. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 2 X X X X X X 3 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 2 2 X 2 Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement To ensure that residents’ changing needs are identified and met, care plans to be reviewed at least monthly. To protect residents and staff and to ensure that all personal allowance expenditure made on behalf of residents is accounted for, an up to date record of transactions to be maintained. To avoid the risk of fire caused through residents smoking unsupervised, risk assessments to be carried out for all residents who smoke. Timescale for action 30/07/07 2. OP18 13 30/07/07 3. OP38 23 30/07/07 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. Refer to Standard OP4 Good Practice Recommendations To ensure that staff develop a broad knowledge of diversity issues in care giving, regarding race, gender, sexuality, age and culture, it is recommended that staff
DS0000025180.V340793.R01.S.doc Version 5.2 Page 24 Speke Care Home 2. 3. OP19 OP36 4. 5. OP38 OP38 6. OP38 7. OP38 receive training in Equality and Diversity. To ensure that the accommodation is suitable for residents, it is recommended that decoration and refurbishment programmes continue to be followed. To ensure that staff are fully supported to fulfil their roles and responsibilities, it is recommended that formal supervision (one to ones) be arranged with all staff every two months. The matters discussed to cover all aspects of practice, philosophy of care and development needs. To minimise the risk of injury to frail residents, a recommendation is made that the accident book be monitored and risk assessment carried out accordingly. To avoid the risk of ineffective fire doors, the double kitchen doors to be checked by a qualified person for gaps when closed on exiting, and remedial work carried out as necessary. To ensure that residents are protected in case of fire and risks are identified and eliminated, it is recommended that the fire authority be consulted concerning the open space between smoking and non-smoking areas. To ensure that staff have the knowledge and skill to take action in case of fire, a recommendation is made that staff receive fire instruction, three monthly for night staff and six monthly for day staff) in addition to fire drills. Speke Care Home DS0000025180.V340793.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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
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