Inspection on 12/01/06 for Steeton Court

This inspection was carried out on 12th January 2006.

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.

Other inspections for this house

Steeton Court 08/08/07

Steeton Court 10/08/06

Steeton Court 19/07/05

Steeton Court 15/12/04

Steeton Court 10/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Steeton Court Steeton Hall Gardens Steeton Keighley West Yorkshire BD20 6SW Lead Inspector Mary Bentley Announced Inspection 12th January 2006 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 Steeton Court DS0000019890.V268740.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. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Steeton Court Address Steeton Hall Gardens Steeton Keighley West Yorkshire BD20 6SW 01535 656124 01535 658436 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) Mr A Spellman Care Home 71 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (61), of places Physical disability (5), Terminally ill (5), Terminally ill over 65 years of age (5) Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That three of the places under the category of PD are for named individuals 19th July 2005 Date of last inspection Brief Description of the Service: Steeton Court is a purpose built property located in a residential area of Steeton close to local amenities and public transport routes. The home is registered to provide care to a total of 71 people. Steeton Court is registered to provide nursing care to older people and there are also a number of places dedicated to the care of the terminally ill. Since the last inspection the home has opened a 10-bed dementia care unit. The home is built on two floors with access to the first floor by means of two passenger lifts and stair lift. The new passenger lift can accommodate stretchers. Accommodation is provided in 61 single and 5 double rooms and all but one have en-suite facilities. There is ample provision of communal space and the new conservatory provides direct access to the grounds from first floor. There is a designated smoking area for residents. Steeton Court has wellmaintained gardens that are easily accessible to wheelchair users. Car parking is provided at the front of the building. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year, from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second inspection of this home and it was announced; the first inspection was unannounced and took place in July 2005. Two inspectors carried out the inspection between 9.30am and 6.15pm on 12 January 2006 and one inspector spent a further 2 hours in the home on the morning of 13 January 2006. There was one visit the to home since the last inspection, this was in response to a complaint; some parts of the complaint were upheld and a brief summary of this complaint can be requested from the CSCI office at Rodley. During this inspection we spoke to residents, relatives, staff and management. We looked at care records and carried out a partial tour of the home. The home completed a pre-inspection questionnaire and the information provided was used during the inspection. One inspector spent most of the first day looking at the way care is delivered on the newly registered dementia unit. The home prefers the term “resident” to “service user” therefore that is the term that will be used throughout this report. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are discussed with the provider without revealing the identity of those completing them. A number of comment cards from relatives and residents were returned to the CSCI before the inspection, the issues raised were looked at and/or discussed during the inspection. Comments made by residents and relatives have been included in the relevant sections of this report. What the service does well: Visitors said that the care staff were very kind, good to the residents and made sure that privacy and dignity were respected. Residents said that they were happy in the home, satisfied with the service provided, they couldn’t ask for better. Residents said they felt safe and well cared for by staff. One resident said, “Everything here is good”. The majority of residents said the food was good and they enjoyed it. Meals are served in the dining room or in residents’ own rooms if they prefer. Residents can choose whether to spend their time in their bedrooms or in one of the many communal areas and there are no restrictions on visiting. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 6 The home has a well publicised complaints procedure and the majority of residents and relatives said they were aware of how to raise any concerns they might have. The home has an Adult Protection procedure in place and both the manager and staff were aware of how to report allegations or suspicions of abuse. The home has good recruitment procedures designed to protect residents. The environment is clean, pleasant and comfortable and all parts of the home are decorated to a high standard. 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. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4 People are helped to make an informed choice by the written information they are given. The needs of prospective residents are assessed before admission however the information obtained during the assessment process is not always used to plan how their care needs will be met. EVIDENCE: A Statement of Purpose is available and sets out clearly the range of services offered by the home. Pre-admission assessments are done for all prospective residents, in most cases this involves the manager of a senior member of staff visiting prospective residents, for residents coming from outside the area information is obtained from family members and other professionals. Prospective residents and/or their representatives are encouraged to visit the home before making a decision about admission. The level of detail in the pre-admissions forms seen varied and it was not always clear when and where the assessment had taken place and who had Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 9 been involved. The needs identified during admission were not always reflected in the care plans. Some people said the home had not lived up to their expectations in terms of how their relatives care needs would be met More information on this is included in the Health and Personal Care Section of this report. . Steeton Court DS0000019890.V268740.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, 9 & 10 The care plans do not reflect all the needs identified during assessment and do not set out clearly how the personal and health care needs of residents will be met. This is likely to result in care needs being overlooked. Some medication practices create the opportunity for residents to be put at risk. EVIDENCE: Five care plans were looked at in detail, two of these were for residents on the dementia unit. The care plans of residents on the dementia unit were to a medical/nursing model and were not person centred. They did not give a clear picture of how to meet resident’s needs. The information for the care plans around sleeping, maintaining personal hygiene and maintaining safety were to a standard format and did not take account of individual needs and abilities. It was clear that staff writing the care plans had not received any training around dementia care. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 11 One plan was for a lady whose husband lives in another part of the home, there was nothing in the care plan to reflect this or say how they were supported in maintaining their relationship. Neither of the care plans gave detailed information about how dementia had affected the residents and what steps staff should follow to meet these needs. The care plans on all units showed a lack of continuity between the information seen in daily records, assessments and the care plans. One plan said that diet and fluid intake was to be monitored but did not say how and did not refer to the nutritional assessment. The care plan did not reflect the fact that the resident had lost weight and did not give any information on dietary preferences, food supplements of food enriching agents. Similar issues were identified in the care plans looked at for residents on other units in the home. Food charts that had been put in place were not filled in consistently. The care plan for an insulin dependant diabetic resident did not give clear details to staff on the times insulin was to be given and where blood sugar levels should be recorded. It did not show what action to take if these were outside the levels agreed with the GP and/or diabetic nurse. Falls risk assessments were done but they did not say what actions should be taken to reduce or minimise the risk of falling. They were not linked to the care plans, for example the phrase “keep a clutter free environment” was used as standard in care plans but in at least one of the rooms seen this would have been almost impossible to achieve. Moving & handling assessments were done but they were not sufficiently detailed, for example for residents with a history of falling the assessments did not give any information on how the residents should be helped following a fall. Relatives had signed most of the care plans seen; however the format used does not lend itself to enabling residents/relatives to add their comments. In one set of records relatives had completed a detailed personal history but none of the information provided had been included in the care plans. Some relatives said that residents had not given a choice of GP on entering the home, the records showed that GPs are allocated to residents by the PCT (Primary Care Trust), while it is acknowledged that this is outside the control of the home it should be made clear to prospective residents and/or their representatives. The home has good systems in place for dealing with the ordering, storage and disposal of medicines. However there was some concern in relation to how medicines that are delivered outside of the monthly order are dealt with as medicines that had been delivered at some point during the afternoon were left unattended on top of one of the medicine trolleys. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 12 There were several gaps on the medicine charts meaning that it was not clear whether medicines had been given or not. On one occasion a medicine trolley was left open and unattended on a corridor while the nurse went into residents rooms and medicines were signed for before they were administered. Some relatives said they had seen tablets left in rooms for people to take and had on occasions found tablets on the floor in bedrooms, no evidence of this was seen during the inspection but it was discussed. Most of the bedroom doors were held open by magnetic door retainers linked to the fire alarm system. The manager said that this was done at residents request, however this should be clarified in the care records to avoid it becoming routine practice. The sleep care plans for residents in the dementia units said that doors were to be left open for staff to easily observe them; this is not good practice as it compromises people’s privacy and potentially adds to the problem of sleep disturbances. Care staff on the dementia unit had a good understanding of the residents and their individual personalities but this was not reflected in the care plans as they do not have a great deal of input into these documents. It was clear that there were good relationships between staff and residents and that the staff were committed to providing a good standard of care to the residents. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Residents living in the general nursing part of the home are given the opportunity to take part in a variety of social and leisure activities and sometimes residents living in the dementia care unit take part in these events. However the overall impression was that for residents on the dementia unit the opportunities to take part in social and leisure activities are limited. Residents are supported in keeping in contact with their families and friends and those who are able to are supported in exercising choices about their daily lives. The majority of residents said they enjoyed the food. EVIDENCE: There were no planed activities for residents on the dementia unit. Staff said that they sit and spend time with residents talking, watching TV or listening to music. If staffing levels permit staff accompany residents on walks. Leisure and social activities are very important for people with dementia and this must form an important part of their care. There is clearly a need for staff training in this area. On other units the home offers a range of activities and the majority of residents said they were satisfied with what was offered. The events planned Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 14 for the forthcoming week including a “Burns” evening with a traditional Haggis supper. Residents and relatives said that there were no restrictions on visiting and visits could take place in private. Each unit has a small kitchenette equipped with a water boiler so that hot drinks can be made at any time. These are not used to their full potential because they do not have fridges. The kitchenette on the dementia unit is very small and barely gives standing room for one; a bigger area would make it possible for residents to use this area with support and/or supervision from staff. Staff said that they could request additional snacks from the kitchen but that it would be easier if they were available on the unit. On the dementia unit the dining tables were not set for lunch because resident’s meals are served on trays and all courses are served at the same time. This means that puddings and drinks may be tepid or cold by the time residents are ready to have them. For residents with dementia there is the additional problem of too many food choices being presented at once. Presenting meals in this way does not provide residents with the opportunity to benefit from the social aspect of meal times. In other units residents can choose to eat in the dining room or in their own rooms. For those residents who choose tray service the same problem, (tepid or cold puddings and drinks), arises as all courses are served at the same time. There was some evidence that communication between nursing/care staff and catering staff is not as good as it could be. The home has a dietary requirement form, which is designed to inform the kitchen staff of residents’ dietary needs, the quality of the information provided on these forms varied and some contained only very basic information such as “normal” diet. Catering staff attend residents meetings and residents are given the opportunity to contribute to planning the menus. Catering staff said the time they could spend with residents outside of these meetings was limited and expressed concern that the quality of the service they could provide was being affected by reductions in staffing levels. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Residents are protected by the homes complaints and Adult Protection procedures. EVIDENCE: The complaint procedure is available in the home and the majority of residents and relatives said they were aware of how to raise any concerns they might have. A complaint was made in July, this was investigated by the CSCI and was partially upheld, and the home is taking action to deal with the issues that were raised. The CSCI received a complaint just before the inspection; this is currently being investigated by the home. There is an ongoing programme of training on adult abuse/protection. Staff said that they would not hesitate to report actual or suspected abuse to the person in charge. Some were aware that they could contact the CSCI and or the local authority adult protection unit. The manager has demonstrated that she is aware of the correct procedures to follow in the event of allegations or suspicions of abuse. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 & 26 Residents live in a clean, pleasant and safe environment. The décor and general environment of the dementia unit has not been adapted to make it more appropriate for people with dementia. EVIDENCE: The home was clean and there were no unpleasant odours. The home is well maintained and decorated and furnished to a high standard. The general décor of the dementia unit, while being to a high standard, could cause problems for residents with dementia for example there is no sign posting and all the doors are white which could make it difficult for residents to find their bedrooms or the toilets. There is limited space for people to walk around and there is no direct access to a safe outdoor area. The lounge and dining room are small and would not comfortably seat all ten residents at the same time. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 17 The majority of bedrooms are suitable for residents needs however one double room occupied by a married couple was rather cluttered making it difficult for the residents to move about safely and not allowing any space for visitors chairs. Residents had their personal belongings around them in their bedrooms. The laundry was clean and tidy and appeared well organised. There are appropriate systems in place for dealing with soiled and/or infected washing. Clothes looked well laundered and ironed. The laundry assistant returns clothes to residents’ rooms. She said that there were problems sometimes when residents clothing not being clearly labelled despite the fact that relatives were asked to make sure that new clothes were labelled. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 There are not always enough staff on duty to meet residents needs. Some staff, particularly those working on the dementia unit have not been given enough training on how to meet the needs of residents they are caring for. Residents are protected by the homes recruitment procedures. EVIDENCE: The manager said that staffing levels were satisfactory. Staff said that numbers of staff on duty varied and often there were not enough to meet the needs of the residents. They said that staff would be moved from one area of the home to another to cover for sickness/absence. This practice should be reviewed particularly for the dementia unit, as these residents need continuity with the staff providing care to them. Some of the staff were not confident about working on the dementia unit because they had not received appropriate training. Some relatives said there seemed to be less staff at the weekends, while the numbers of nursing and care staff on duty are the same as during the week there is no reception cover at weekends meaning that staff have the additional responsibility of answering the phone and dealing with visitors. The manager said she was considering appointing a weekend receptionist. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 19 20 of care staff are qualified to NVQ level 2 or above and a further 25 staff are enrolled on NVQ training. There is a detailed induction programme for all new staff. The home is making good progress with mandatory training, the majority of staff have received training in moving & handling, fire safety and health and safety. It was clear during the inspection that more training is needed particularly in the areas of dementia care and care planning. The files of three recently appointed staff showed that all the required preemployment checks are done before they start work in the home. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 35, 36 & 38 The inspection identified a number of issues around communication and staff morale and these have the potential to have an unfavourable effect on the quality of life experienced by residents in the home. The financial interests of residents are safeguarded. EVIDENCE: The manager is a nurse with many years relevant experience; her application to be registered by the CSCI is still being processed. Staff meetings are held at regular intervals. But staff said that these were of little benefit because the same issues were discussed over and over and nothing changed. One said that they thought an action plan with timescales should be put in place after these meetings. They felt that there was a lack of continuity in work practices and poor communication generally. Staff morale was low in all areas of the home and care staff said they did not feel valued; Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 21 criticism was quick to come but positive feedback rarely given. There are systems in place for staff supervision but the issues identified around staff morale call into question the effectiveness of this supervision. The home does not get involved in dealing with residents’ financial affairs, if necessary residents are helped to get independent support with this area. Small amounts of spending money are held for some residents, all transactions are recorded and signed for. Residents are given itemised accounts each month for any additional services that they have had. Accident records are kept and are audited monthly by the manager but there was no evidence that the audit had been used to review care practices, for example for residents who were identified as having frequent falls there was nothing in the care plans to show what action was being taken to minimise the risk of further falls. Despite the fact that there is an ongoing programme of moving and handling some relatives raised concerns about practices they had observed in the home, no evidence of poor practice was seen during the inspection but the manager was made aware of these concerns. A maintenance man is employed and he does the weekly fire alarm system tests, monthly hot water outlet checks, electrical appliance testing and general repairs and maintenance. Specialist engineers as called as needed for larger equipment and installations such as the hoists, lifts and central heating systems. The pre-inspection questionnaire showed that equipment is serviced and maintained at the required intervals. Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 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 3 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X 2 3 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X X 3 2 X 2 Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 23 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 15 Requirement Care plans must set out in detail how all the needs identified by the assessment process will be addressed. The plans must provide evidence of involvement by residents and/or their representatives. Previous timescale of 31/10/05 not met. When residents are identified as being at risk, for example of developing pressure sores, of falling or in relation to nutrition care plans must be put in place to show what action is being taken in response to this risk. Previous timescale of 31/10/05 not met. The registered persons must make sure the correct procedures for the safe storage and administration of medicines are followed. The registered persons must make sure that all residents are given the opportunity to take DS0000019890.V268740.R01.S.doc Timescale for action 12/05/06 2 OP8 17 Sch 3 12/05/06 3 OP9 13 31/03/06 4 OP12 16 21/04/06 Steeton Court Version 5.0 Page 24 5 OP26 16 part in social and leisure activities that take into account their interests and abilities. The provision of laundry services must be reviewed to ensure that service users personal clothing is clearly identified. Previous timescale of 30/09/05 not met. The registered persons must make sure that there are at all time enough staff on duty to meet residents needs. All staff must be provided with appropriate training to equip them to meet the needs of the residents in the home, particular attention must be given to the areas of dementia care and care planning. The registered persons must address the issues of communication and staff morale identified during the inspection. 12/05/06 6 OP28 18 31/03/06 7 OP30 18 12/05/06 8 OP32 12 31/03/06 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 Refer to Standard OP3 OP7 OP8 OP8 Good Practice Recommendations The pre-admission assessment records should state clearly when and where the assessment took place and who was involved. Consideration should be given to changing the care plan format to allow residents and/or their representatives’ space to add their comments. The falls prevention team should be contacted for advice on the management of residents with an identified risk in this area. Prospective residents should be made aware that choice of GP may be limited if GPs are to be allocated by the local DS0000019890.V268740.R01.S.doc Version 5.0 Page 25 Steeton Court 5 OP10 Primary Care Trust. The practice of holding bedroom doors open on the dementia unit at night should be reviewed. Consultation with residents with regard to whether they want their bedrooms doors held open or closed should be reflected in the care records. The current system of tray service, whereby all the courses are served at the same time, should be reviewed. Consideration should be given to how the environment on the dementia unit could be improved to make it more appropriate for the residents living there. The suitability of the double room, discussed during the inspection, to meet the needs of the residents should be reviewed. A minimum of 50 of care staff should be trained to NVQ level 2 or equivalent. 6 7 8 9 OP15 OP20 OP23 OP28 Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Steeton Court DS0000019890.V268740.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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