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Inspection on 11/10/05 for St Ann`s Residential Home

Also see our care home review for St Ann`s Residential Home for more information

This inspection was carried out on 11th October 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents said that the meals served in the home were good and ideas from residents, for new items on the menu, have been tried. One of the residents continues to be involved in writing out the menu for the week. Residents all have their own single bedrooms, many with en suite facilities and some residents choose to spend time in their rooms, during the day. They are able to relax in their rooms, without unnecessary interruption, and to sit with their friends. Residents said that the staff were kind and staff were knowledgeable about the individual likes and dislikes of residents. They spent time sitting and talking with residents and giving the resident individual attention. Carers have access to a programme of NVQ training and 7 members of staff are waiting to receive their NVQ level 3 certificates from the awarding body. The home is to be commended as this level of qualification is higher than the recommended level for carers in homes for the elderly.

What has improved since the last inspection?

The ramp to the front of the home, providing level access for a resident or for a visitor using a wheelchair, has now had the safety rails fitted each side of the ramp. The new washing machine that was purchased for the home has now been connected and was in use during the inspection. The weekly list of activities is on display in the open plan lounge area.

CARE HOMES FOR OLDER PEOPLE St Ann`s Residential Home 125 Chalkhill Road Wembley Park Middlesex HA9 9AL Lead Inspector Julie Schofield Unannounced Inspection 11th October 2005 11:35 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 St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Ann`s Residential Home Address 125 Chalkhill Road Wembley Park Middlesex HA9 9AL 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) 020 8908 2033 020 8904 2856 Capital Investments & Devlp Ltd Mrs Yetunde Majekodunmi Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2005 Brief Description of the Service: The home is registered to provide personal care for up to 16 service users. At the time of the inspection there were 13 residents and 3 vacancies, although 1 resident was in hospital. St Ann’s is situated close to Wembley Park underground station and main bus routes. It is also close to a parade of shops and to a supermarket. At the front of the home there is a large paved area for off street parking. (There are parking restrictions in the road immediately outside the home). Service users are accommodated in bedrooms on both ground and first floors and there are bathing and toilet facilities on both floors. Eight of the bedrooms have en suite facilities. There is a passenger lift connecting ground and first floor. Staff accommodation is situated on the second floor. The office, open plan dining and lounge areas and kitchen are situated on the ground floor and the laundry room is situated on the first floor. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection started at 11.35 am and finished at 4.05 pm. During the inspection the Inspector met the manager and the proprietor. Residents’ records were inspected, a site visit took place and the serving of the midday meal was observed. The Inspector would like to thank the manager, proprietor, members of staff and residents who took part in the inspection. A resident said that residents were well looked after and that living in the home was like a holiday. What the service does well: What has improved since the last inspection? St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 6 The ramp to the front of the home, providing level access for a resident or for a visitor using a wheelchair, has now had the safety rails fitted each side of the ramp. The new washing machine that was purchased for the home has now been connected and was in use during the inspection. The weekly list of activities is on display in the open plan lounge area. What they could do better: Care plans need to include a risk assessment for the prevention of falls and the home needs to ensure, by contacting the placing authority if necessary, that review meetings are held on a six monthly basis. The programme of activities in the home needs to be expanded and to include more activities taking place outside the home. By keeping to the activities listed on the board residents will become aware that a programme is being followed and this may encourage more participation. The home must address the problem of the number of cars using the parking area at the front of the home as it could hinder access by the emergency services. There is work needed in the garden to clear away rubbish, to maintain the lawn area and provide patio furniture before this area is a pleasant feature of the home. The maintenance programme in the home needs to quickly respond to repairs needed or to deterioration in items of furniture. The disposal of clinical waste must be safe and hygienic. Kitchen appliances need to be appropriately sited, not in the lounge areas. Complaints must be recorded and there must be a comprehensive system for obtaining the views of residents, their relatives and other visitors to the home about the quality of service provided. Records must be accurate in relation to residents’ finances. The rota must reflect a team of staff, sufficient in numbers to meet the needs of the residents and more staff are needed at the weekend. In order to effectively supervise staff and to ensure that the quality of care is consistent both during the week and at the weekend the manager should work occasional shifts at the weekend. Care must be taken to preserve the dignity of residents at all times by ensuring that they are appropriately dressed in communal areas. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 7 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. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 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 St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Prior to admission, information is received about the prospective resident and the manager carries out an assessment to ensure that the needs of the resident can be met within the home. EVIDENCE: The case files of the last 3 residents to be admitted to the home were inspected. Each of the residents had been admitted to the home since the last inspection and had been admitted on an emergency basis. On each case file there was evidence that the home had received information from the placing authority, prior to the admission of the resident. The manager had visited the resident prior to admission and each file contained a care plan that the home had developed. The home does not offer an intermediate care service. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 Evaluating care plans and holding regular review meetings ensures that changes in the needs of residents are identified and can be addressed. The home must ensure that review meetings, convened either by the placing authority or by the home, take place at least twice a year. Risk assessments for the prevention of falls are needed so that staff can support residents to enjoy an independent lifestyle. Residents’ health care needs are met through access to health care services in the community although it is recommended that the regularity of a check by the optician be increased. While residents should be able to choose what to wear so that they feel comfortable staff should encourage residents to wear clothing that protects their dignity and privacy. EVIDENCE: The case files of the last 3 residents to be admitted to the home and of 3 other residents selected by the Inspector were examined. Case files contained care plans and monthly evaluations, which were up to date. Although there were risk assessments for the prevention of pressure sores the files did not contain risk assessments for the prevention of falls. While the recently admitted residents had not yet been in the home for 6 weeks there was no evidence that St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 11 the date for an initial review meeting had been arranged. An external review meeting for 2 of the 3 other residents was overdue, as were the internal reviews for these 2 residents. A resident said that residents in the home have been offered appointments to have a flu jab. The monthly records of the weight of residents, on the files selected for inspection, were up to date and complete. Case files contained evidence of access to the optician (on a 2 yearly basis) and a separate book was available that listed residents’ health care appointments i.e. chiropodist, dentist, GP and out patient appointments. Referrals had been made to the continence adviser and the speech therapist, as required. One of the residents sitting at the dining table was wearing a nightdress but not a dressing gown. It was warm and the resident was aware of what they were wearing and confirmed that this was their choice. However, it compromised the dignity of the resident in front of other residents and visitors. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Providing activities for residents, both inside and outside the home, offers residents an opportunity to develop their social and communication skills and to enjoy an interesting and stimulating lifestyle. The home needs to increase the range of activities available, which at present are limited, and this may encourage more participation. The support of staff enables residents to maintain family contact. However the home needs to review parking arrangements as the overcrowded car park could hinder access to the emergency services. Residents have a varied and balanced diet and said that they enjoyed the meals served in the home. EVIDENCE: A discussion took place with the manager about activities available to residents. Two residents said that they did not wish to take part in activities and the manager said that some of the residents who do participate, do not wish to take part every time. Staff said that some residents preferred to sit and chat with a member of staff, on an individual basis. During the inspection a game of bingo took place. It was not the activity listed on the notice board for a Tuesday. The manager confirmed that few activities took place outside the home, apart from going to the corner shop. There were boxes of games in the lounge. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 13 When the Inspector arrived at the home and parked in the parking area at the front of the house there were already 8 cars parked. Of the 8 cars parked outside the home only 2 belonged to visitors. (One visitor was visiting a resident and the other visitor was from the LFEPA). Cars parking in front of the house rather than on each side of the parking area restrict access to the front door and could hinder access by the emergency services. This has been brought to the attention of the manager and the proprietor previously. Some of the residents said that their relatives visited them at St Ann’s and that the staff on duty made their relatives welcome. The daily food records demonstrated that residents exercised choice in respect of the meals consumed. A record is kept of which dish is selected at mealtimes. Residents said that they were able to choose whether they took part in activities. Residents were able to spend time in their rooms, without unnecessary interruptions, as they wished. During the inspection a midday meal was prepared and served and details of this were on display in the lounge. It consisted of fish pie, creamed potato and spinach and the dessert was spotted dick and custard. Residents said that they enjoyed the meal and that the food served in the home was good. Staff assisted residents with feeding in a discreet and sensitive manner. A discussion took place with the member of staff who cooked the meal and she said that it was important for residents to have a tasty meal that they could eat without discomfort. She also said that this had been a meal that had been suggested by the residents. A resident said that she still filled out the master copy of the menu and that residents were involved in menu planning. Copies of the menus were examined. They included a choice of 2 main meals and 2 desserts for the lunchtime. However sometimes the 2 main meal choices involved the same ingredient i.e. chicken stew or chicken in a red wine sauce. At present a diabetic diet is provided for one resident and a pureed diet is provided for another. Daily records of what each individual resident consumed are kept and were up to date and complete. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The purpose of a complaints procedure is to protect the rights of the resident and the home must be able to demonstrate that the procedure is followed when a complaint is made. By failing to keep records the home is unable to demonstrate this. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: A copy of the complaints procedure was on display in the entrance hall of the home and it advised the complainant of their right to contact other agencies if they were not satisfied i.e. the CSCI. Details of the address and telephone number of the local CSCI office were included in the procedure. A copy of the complaints procedure was also on display in the residents’ bedrooms. The manager said that 1 complaint had been received since the last inspection but this had not been recorded. Four residents said that there was some one in the home they could speak to if they had a complaint. The home has a protection of vulnerable adults policy and there is a link with the local authority’s interagency guidelines in the event of abuse. Staff have undertaken protection of vulnerable adults training, either as part of their NVQ studies or on specialised courses (certificates held on staff files). The manager confirmed that no incidents or allegations of abuse have been recorded since the last announced inspection and that the home does not practice restraint. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26 Residents need a comfortable environment in which they can relax. Although the upkeep of the home is generally good, and on the day of the inspection builders were carrying out minor repairs, the work that was needed in one of the bedrooms was outstanding from the previous inspection in May 2005. Residents are unable to enjoy using or looking at the garden, as work needs to be done to make this a pleasant and safe facility. With access to comfortable lounge and dining areas and their bedroom, which residents said they were pleased with; residents had a choice of socialising or enjoying their privacy. Residents’ comments regarding facilities need to be acted upon if an early resolution to a problem is to be found. In order that standards of hygiene are maintained the home needs to review its handling of clinical waste. EVIDENCE: A site inspection took place and although most of the rooms were in a good state of repair there was a hole in the ceiling of room 12 and tiles missing from the ensuite. The ceiling in room 11 had been repaired but needed St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 16 redecorating. At the front of the house handrails have now been fitted to the ramp to the front door. During the inspection builders were on site carrying out minor repairs. Although the garden had been tidied and shrubs and flowers planted after some building works at the end of the garden had been completed it has not been well maintained. Before the garden is a pleasant view for those residents whose bedroom window overlooks it and before residents are able to enjoy sitting in the garden, the old kitchen appliances and rubbish that are stored there need to be removed. Patio furniture that is suitable for outdoor use and suitable for use by elderly residents needs to be provided. The grass needs to be cut and weeds need to be removed. The ornamental lampposts need light bulbs and covers to make them operational. There was sufficient comfortable seating in the lounge for residents and there were dining tables and chairs for those who wished to sit together to eat. There were also tables, which could fit over the chair so that residents could eat sitting in their chair in the lounge rather than at the dining table. In the lounge area there was a 2 seater settee, close to the office, which was becoming threadbare in places. Next to the settee was a chair without a seat cushion. The television was placed on a wooden crate that had been covered with Christmas paper. There were 2 small fridges in the lounge area. One was locked and it was used to store a resident’s supply of insulin. Residents said that they were satisfied with their rooms and that they were comfortable. One of the residents said that they were only able to receive one channel on their television and had reported this. As televisions in vacant rooms were able to receive at least 4 channels the manager agreed to change over televisions while the problem was investigated and rectified. During the site inspection it was noted that the home was clean and free from offensive odours. Residents said that the home was kept clean and tidy. However in the ground floor shower room a bag of clinical waste was almost full of used incontinence pads and was open at the top. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 Although residents said that members of staff were kind, the rota did not demonstrate that there were always sufficient members of staff on duty to support the residents and to meet their needs. Residents receive support from trained staff that have developed their skills and knowledge and their understanding of the needs of the elderly. EVIDENCE: At the start of the inspection the manager and 2 members of staff were on duty. A trainee on work experience was also present in the home. The rota was examined. One of the carers listed on the rota had reported sick and was not on duty. A member of staff who usually performed catering and domestic duties was covering the carer’s duties. The manager’s hours were recorded on the rota. While the manager worked early and late shifts during the week, the manager did not work in the home at the weekend. On certain shifts at the weekend there were only 2 carers on duty. As domestic and catering staff finish their shifts at 1pm there would be insufficient staff on duty to meet the needs of the service users between 1pm and 8pm, when the night staff take over. This was brought to the attention of the manager who agreed that at the weekend a minimum of 3 carers would be on duty on each shift during the day. At night there were both waking and sleeping in but on call staff on duty in the home. Four of the residents who took part in the inspection said that the staff were kind. A discussion took place regarding all the carers listed on the rota and NVQ training. The manager said that 7 carers had completed their NVQ level 3 St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 18 training courses and were waiting for their certificate from the awarding body. This was above the recommendation in the National Minimum Standards – Care Homes for Older People for 50 of carers to achieve an NVQ level 2 qualification. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 38 The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. Residents, relatives and visitors to the home need the opportunity to comment on the quality of the service provided so that services can develop according to the needs of residents. Records of money kept in safekeeping for residents protect the financial interests of residents and balance sheets need to accurate. During the inspection the balance sheet for one residents was inaccurate. In the event of an accident or incident occurring in the home there is insurance cover to protect residents, members of staff and visitors to the home. Fire precautionary systems and equipment help safeguard residents, staff and visitors. The preparation of meals needs to be in an environment where insects are prevented from entering the kitchen, to prevent contamination and the home needs to install mesh screens. EVIDENCE: St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 20 The manager, who is a qualified nurse, has completed the Health and Social Care level 4 Registered Manager’s Award training course and is waiting for the certificate from the awarding body. (The manager was waiting for the certificate when the home was inspected in May 2005). She said that she has recently completed the NVQ Assessors Award and her portfolio is ready for assessment and verification. The manager said that residents’ satisfaction survey forms are used in the home. There were 3 forms available that had been completed in May 2005. Satisfaction survey forms are not sent to or given to relatives or professional visitors to the home. The manager said that the home was responsible for handling the personal allowance of one of the residents but this resident was currently in hospital. The record of the money currently held on behalf of the resident was available and was satisfactory. The family of one of the residents leaves money in the home for the resident’s day to day living expenses. The records were inspected and these were incorrect. According to the amounts deposited by the relatives, and the amounts spent on behalf of the resident, the account should have been in debit but the records showed a credit. There was certificate of Employer’s Liability insurance cover on display in the home that was valid for the period 22/4/05 to 21/5/06. It provided cover up to a minimum of £5 million. The visitor from the LFEPA said that he had spoken to a person working in the home and was satisfied that they would implement the recommendations made. He was generally satisfied with fire precautionary arrangements in the home and has confirmed this in writing, to the home and to the CSCI. Mesh screens have not been fitted to kitchen windows to prevent insects from entering. St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 2 X X X 3 X 2 STAFFING Standard No Score 27 2 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 2 3 X X 2 St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13.4 Requirement That a risk assessment, paying particular attention to the prevention of falls, is on each resident’s case file. (Previous timescale of 01 October 2005 not met). That the home contacts the placing authority to ensure that the regularity of review meetings is maintained. (Previous timescale of 01 September 2005 not met). That staff encourage residents to wear a dressing gown over nightclothes when they are seated in communal areas. That the programme of activities, both inside and outside the home, is reviewed with residents and increased. That parking in front of the building does not interfere with access to the home by the emergency services. That a record is kept of all complaints made. That the repairs needed in bedroom 12 are carried out i.e. to repair and make good the DS0000017440.V257026.R01.S.doc Timescale for action 01/01/06 2 OP7 15.2 01/12/05 3 OP10 12.1 01/12/05 4 OP12 16.2 01/01/06 5 OP13 12.1 01/12/05 6 7 OP16 OP19 17.2S4.11 23.2 01/12/05 01/01/06 St Ann`s Residential Home Version 5.0 Page 23 8 OP19 23.2 9 OP20 23.2 10 OP20 16.2 11 OP26 16.2 12 13 OP27 OP33 18.1 24.1 14 OP33 24.1 15 16 OP34 OP38 17.2S4.9 16.2 hole in the ceiling and to replace the missing tiles in the ensuite. (Previous timescale of 01 October 2005 not met). That the repairs needed in bedroom 11 are carried out i.e. to redecorate the ceiling where a repair has been carried out. That old domestic appliances and rubbish are removed from the garden, that the grass is cut and weeds are cleared, that suitable patio furniture is provided and that the ornamental lamp posts are maintained in working order That the 2 seater settee is replaced, a seat cushion is provided for the chair and that the television table has a suitable covering. That clinical waste i.e. incontinence pads are placed, in bags, into a pedal bin, with a lid, and then transferred at least twice a day to the clinical waste bin outside the home. That the number of staff on duty at the weekends is sufficient to meet the needs of residents. That the home seeks feedback from residents about the service received e.g. by the use of the annual satisfaction survey, holding regular residents’ meetings etc. (Previous timescale of 01 October 2005 not met). That the home seeks feedback from relatives and professional visitors to the home about the service provided. That the records of money kept on behalf of a resident are accurate. That mesh screens are fitted to the kitchen windows to prevent insects entering. (Previous timescale of 01 October 2005 DS0000017440.V257026.R01.S.doc 01/01/06 01/12/05 01/12/05 01/12/05 01/12/05 01/01/06 01/01/06 01/12/05 01/01/06 St Ann`s Residential Home Version 5.0 Page 24 not met). 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 OP7 Good Practice Recommendations That the home devises a system for noting the date of the last review meeting so that contact can be made with the placing authority, if an external review is due, or a date can be set if an internal review is due. That the home contacts the placing authority towards the end of the 6 week period, after the start of the placement, to check that a date has been set for the initial review meeting. That annual checks by the optician are arranged for residents. That the activity taking place in the home is the activity listed on the board in the lounge, for that day. That cars do not park in front of the house but along the side walls of the front of the parking area. That a choice of food item is offered at a meal e.g. chicken or fish rather than 2 different chicken dishes. That the 2 fridges are removed from the lounge. That all televisions in the home are in working order and able to receive the channels available. That the manager works occasional weekend shifts in the home to ensure consistency in the quality of care. That the manager requests that the certificate for her RMA training course is forwarded to her as soon as possible. 2 OP7 3 4 5 6 7 8 9 10 OP8 OP12 OP13 OP15 OP20 OP24 OP27 OP31 St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Ann`s Residential Home DS0000017440.V257026.R01.S.doc Version 5.0 Page 26 - 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. 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