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Inspection on 15/05/06 for Swallows Residential Home

Also see our care home review for Swallows Residential Home for more information

This inspection was carried out on 15th May 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.

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

The day-to-day care and support offered to residents is done well and sensitively. Nearly all the residents spoken with said they liked the home and the staff were so kind and willing to help them. Residents also commented that the food was very nice and they had plenty of choice.

What has improved since the last inspection?

Since the last inspection further decoration has taken place and more residents` rooms have been redecorated, the kitchen has been painted as have a number of wooden window frames. The boiler cupboard in the laundry room is no longer used to air clothing or store bedding. The dining room has been rearranged to allow for easier access by residents with walking aids.

What the care home could do better:

Some fire doors continue to be wedged open and one corridor used as a fire exit was extremely cluttered. MAR sheets are not being completed correctly and some prescriptions give ambiguous instructions. There was not evidence that all the correct recruiting checks are being made. The Registered Manager must notify the Commission when their absence exceeds 28 days.Residents` files seen did not have evidence of a pre-admission assessment of need undertaken by the home and care plans did not cover all the identified needs nor were they updated. There was no evidence of any contract with the Swallows for their care only a Social Services contract. The duty rota did not show the hours the manager worked at the home or the staff surnames or grades. The Control of Substances Hazardous to Health (COSHH) folder was incomplete and the Health and Safety folder was from Suffolk Social Services and not relevant to the Swallows. Some stored food in the refrigerator was not covered properly, not labelled or dated. The jugs used to serve drinks at lunchtime were plastic measuring jugs that were badly stained. The toilet in the entrance hall was partially carpeted and could pose a tripping hazard. Some residents` rooms contained a lot of piled up packs of pads and equipment for the community nurse to do dressings, out in the room not stored in cupboards. Some working documents had been removed from the premises so the manager could work on them elsewhere.

CARE HOMES FOR OLDER PEOPLE Swallows Residential Home Helions Bumpstead Road Haverhill Suffolk CB9 7AA Lead Inspector Jane Offord Key Unannounced Inspection 15th May 2006 09:50 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 DS0000063929.V295511.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. DS0000063929.V295511.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swallows Residential Home Address Helions Bumpstead Road Haverhill Suffolk CB9 7AA 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) 01440 714745 01440 761315 Burrows Care Homes Miss Annmarie Burrows, Mr Harold Burrows, Mrs Donna Burrows Mrs Megeita Barrett Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000063929.V295511.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: The Swallows residential home offers care and accommodation for up to sixteen older people, in single storey accommodation situated on the outskirts of the town of Haverhill in a rural position. The home was first registered in 1995 and the building adapted to provide appropriate accommodation for seven residents. In February 2000 an extension was completed, providing good quality and pleasant additional communal and bedroom accommodation and increasing the registration of the home to fifteen. In November 2000 a previous office was converted into an additional resident bedroom and the total again increased to sixteen residents. All resident bedrooms are for single occupancy with one room having an ensuite toilet facility. The home came under new ownership and management in June 2005 and the new owners have already made changes to improve and upgrade the environment. DS0000063929.V295511.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection focussing on the core standards for Older People. It was undertaken by two inspectors during a weekday between the hours of 9:50 and 16:30. The manager was not on duty but the deputy manager was available to assist the inspection process throughout the day. Two residents files and two new staff files were seen, the duty rotas, the complaints log, the menus and equipment maintenance records were also inspected. A medication round was observed and the medication administration records (MAR sheets) were checked. A number of policies were read and discussions were held with the deputy manager, several residents, a visitor and a number of staff. A tour of the building was undertaken and the serving of the lunchtime meal was seen. On the day of inspection the home felt calm and was clean and tidy. Residents were spending time in the lounges or their own rooms and interactions between staff and residents were appropriate and friendly. All the residents were tidily dressed and looked comfortable. Staff were relaxed and cooperated in the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Some fire doors continue to be wedged open and one corridor used as a fire exit was extremely cluttered. MAR sheets are not being completed correctly and some prescriptions give ambiguous instructions. There was not evidence that all the correct recruiting checks are being made. The Registered Manager must notify the Commission when their absence exceeds 28 days. DS0000063929.V295511.R01.S.doc Version 5.2 Page 6 Residents’ files seen did not have evidence of a pre-admission assessment of need undertaken by the home and care plans did not cover all the identified needs nor were they updated. There was no evidence of any contract with the Swallows for their care only a Social Services contract. The duty rota did not show the hours the manager worked at the home or the staff surnames or grades. The Control of Substances Hazardous to Health (COSHH) folder was incomplete and the Health and Safety folder was from Suffolk Social Services and not relevant to the Swallows. Some stored food in the refrigerator was not covered properly, not labelled or dated. The jugs used to serve drinks at lunchtime were plastic measuring jugs that were badly stained. The toilet in the entrance hall was partially carpeted and could pose a tripping hazard. Some residents’ rooms contained a lot of piled up packs of pads and equipment for the community nurse to do dressings, out in the room not stored in cupboards. Some working documents had been removed from the premises so the manager could work on them elsewhere. 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. DS0000063929.V295511.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000063929.V295511.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6. People who use this home can expect to be assured that their needs, as assessed by Social Services, can be met but they cannot be assured that they will have a contract setting out the terms and conditions of their care with the Swallows. The home does not offer Intermediate Care. EVIDENCE: Two residents’ files were inspected, one of a resident recently admitted and one for a resident who has been in the home over a year. Neither file contained a contract setting out terms and conditions with the Swallows. The deputy manager said that contracts are not signed until after the six-week trial period so the new resident would not yet have one, however there was no evidence that terms and conditions had been discussed with them. The file of the other resident contained a contract between them and Social Services but not a Service User agreement between the resident and the Swallows. DS0000063929.V295511.R01.S.doc Version 5.2 Page 9 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, 11. People who use this service can expect to have their care needs set out in a care plan and to be treated with respect. However they cannot be assured that the medication administration practice will protect them, that the service has the information to fulfil their final wishes or that all their health needs will be met. EVIDENCE: In the two residents’ files seen there was evidence that an assessment of need was undertaken after admission and a care plan generated. Areas of care that were identified were personal hygiene, communication, mobility, preferences around getting up and going to bed, likes and dislikes, dressing and undressing, oral care and continence. Some interventions were written to promote independence such as ‘able to wash and dry hands and face unaided’. There was documented evidence of nutritional and tissue viability assessments, records of weight and preferred activities. The files contained information relating to past medical history and the medication regime that the resident was on at admission. There were records of visits from or to health care professionals such as GP, community nurse, physiotherapist, chiropodist and optician. DS0000063929.V295511.R01.S.doc Version 5.2 Page 10 On the day of inspection the deputy manager was overheard discussing an optician’s appointment with one of the residents and a chiropodist’ appointment with another. One resident and their relative spoken with said some of the care they received did not meet their needs. The resident had been prescribed a continence aid for use at night but care staff had to apply it. The care staff had refused to apply it so the resident was suffering broken sleep, as they had to get up frequently during the night. There was a prescribed regime for managing an infection that the resident had that involved daily cleansing of their hands. The resident said this did not happen on a daily basis. There had also been problems in that staff did not wash and dry the resident’s groin area properly and the resident often suffered soreness as a result. The care plan for this resident did not have interventions for all the identified needs and those that did had no evidence of review or updating. In the entrance hall of the home together with the Service Users guide there was a Home’s Brochure. The brochure detailed a lot of the services offered by the Swallows among them how residents could expect to be cared for during terminal illness and death entitled ‘Dying Person’s Bill of Rights’. Neither of the residents’ files seen had written evidence that their final wishes had been discussed. Staff were observed knocking on the doors of residents’ rooms before entering and asking if it was convenient to make beds or perform care tasks. A member of staff was seen to kneel down to have a conversation with a resident so they could make eye contact. During the lunch food and drinks were offered for the residents to make their own choices. The medication administration round was followed and residents were asked if they wanted their medication during the meal or afterwards. Help, when required, was offered sensitively. The medicine cupboard was secured each time the carer left it. MAR sheets were seen and there were found to be gaps in the signature boxes and some codes used incorrectly. ‘As required’ (PRN) medication that had a choice of dose did not always have the dose administered recorded. Some hand written prescriptions copied, the deputy manager said, from the containers were ambiguous. One prescription for a painkiller said ‘give two tablets three times a day’. For two days the MAR sheet had been signed that the medication had been given four times a day. DS0000063929.V295511.R01.S.doc Version 5.2 Page 11 One MAR sheet had ‘self medicates’ written beside a prescription for controlled release morphine sulphate tablets (MST), which is a controlled drug (CD). When questioned about the prescription the deputy manager said it was a mistake, the resident did not self medicate that drug. DS0000063929.V295511.R01.S.doc Version 5.2 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, 14, 15. People who use this service can expect to be encouraged to maintain contact with family and friends, to be offered meaningful activities but have a choice of how they spend their time and receive a balanced diet. EVIDENCE: Residents’ files seen record the resident’s interests and preferred activities prior to admission. One resident regularly attended Bingo in Haverhill before coming into the home and has been able to continue to attend. Another resident enjoys knitting and spends a lot of time knitting squares to be made into blankets. On the day of inspection one lounge area had a tape playing of 60s songs and in the other area residents were having general conversation or reading. Activities usually take place during the afternoon when staff members facilitate game such as dominoes, I-spy, doing jigsaws and reminiscence talks. A carer said that one member of staff had asked residents to help fold some small pieces of laundry and that had generated a discussion about how laundry days had changed over the years. The home has visiting people who conduct flower arranging and craft sessions on a weekly basis. DS0000063929.V295511.R01.S.doc Version 5.2 Page 13 There were a number of flyers around the home advertising a selection of planned events such as ‘Meadow Lark – music on the meadow with fireworks’, ‘On the home front – reminiscence’, ‘Sing along with Hank’ and ‘Golden Oldies 50s and 60s’. Lunch served on the day of inspection was chicken burgers and chips with spaghetti or tinned tomatoes. Dessert was ‘Angel Delight’ and for tea there were home made cakes. One resident said ‘the food is very good. The cook feeds us up’. They went on to explain that they enjoyed a fried breakfast of egg, bacon and fried bread some days. One resident has recently gained weight and this has been restricting their mobility. The cook offers healthy options to this resident such as salads, fruit or yoghurts as alternatives to the planned menus. During lunch there was a choice of drinks offered and served by the care staff. It was noticed that orange juice was in a glass jug but two varieties of squash were served in badly stained plastic measuring jugs. The dining tables all had pretty tablecloths and each resident had a material serviette as well as clothing protection if it was needed. The meal was hot and the residents clearly enjoyed it. Residents’ files had recorded the next of kin and their contact details. Residents and staff spoken with said there was no restriction on visiting. One resident frequently returned home to spend a weekend with their spouse. DS0000063929.V295511.R01.S.doc Version 5.2 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. People who use this service can expect to have complaints taken seriously and investigated. They can expect staff trained to protect them from abuse but cannot be assured that the policy links with the local guidelines. EVIDENCE: CSCI have not received a complaint about this service since the last inspection. The complaints policy was seen and showed a robust procedure, with timescales, for managing a complaint investigation, offering a written response at the close of the proceedings. The home does have copies of the Inter-Agency Policy Operational Procedures and Staff Guidance June 2004 from the Vulnerable Adult Protection Committee in Suffolk. The home also has their own written policy but it does not cross reference to the Suffolk guidelines. There was evidence in the staff training files that POVA training has been accessed for staff and is included in new staffs’ induction. DS0000063929.V295511.R01.S.doc Version 5.2 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, 22, 24, 25, 26. People who use this service can expect to live in a clean, well-maintained home but they cannot be assured that there is adequate storage for equipment and aids or that the water is regulated to a safe temperature. EVIDENCE: Since the new owners have been in place a programme of redecoration has been established. Residents’ rooms that become vacant are routinely redecorated. The kitchen has been painted recently and looks nice and fresh. There are plans to put new curtains in the lounge but the owners are having difficulties finding a firm who fit curtain rails around a bay window. The gardens have been cleared and new grass sown. The owner said they have plans to plant the area when the weather is a little better. There are large pots already for bedding plants to brighten up the front of the house. All the bathrooms and toilets seen were clean and none of them had any unpleasant odours. During the day there was one episode of an odour that lingered in one corridor but did dissipate after a short period. DS0000063929.V295511.R01.S.doc Version 5.2 Page 16 Residents’ own rooms were attractively decorated and contained many personal items that people had chosen to bring with them. One resident’s file noted that the resident had been offered the option of keeping their room locked and taking responsibility for the key. The resident had declined and the key was kept on a hook outside the room. Some residents needed continence pads and dressings for wound care and several of their rooms had stores of these for the resident. However they were not stored in cupboards but stacked on the floor or wardrobe in full view of any visitors and the resident. Other items of equipment such as wheelchairs and hoists were left in corridors and posed a fire hazard. The laundry was seen and there was no evidence that the boiler cupboard was being used inappropriately to air clothes and store bedding. The washing machine has a sluicing facility for soiled linen. A member of staff was able to explain the procedure for managing soiled laundry. The home uses alginate bags to reduce the risk of handling infected linen and provides protective clothing for staff use. All hand washing areas had a supply of liquid soap and paper towels. Water temperatures were checked and recorded and showed a variation between 38 degrees and 41 degrees, however there was one instance of the temperature being 45 degrees, which is over the recommended safe limit. DS0000063929.V295511.R01.S.doc Version 5.2 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, 29, 30. People who use this service can expect to be cared for by suitably trained staff in sufficient numbers to meet their needs but they cannot be assured that the correct recruitment checks are carried out or that the duty rota reflects the staff on duty. EVIDENCE: The duty rotas were seen and showed staffing of two carers on duty throughout the day with one waking and one sleeping carer at night. In addition there was a senior member of staff working 8.00-17.00 each day. There was a cook daily but the domestic post remains unfilled. The registered manager’s duty was not shown and there was no indication whether they were working, taking annual leave or off sick. No members of staff were identified by surname and there was no indication of grades. On arrival on the day of inspection a driver/handy person was in the office and about to test the fire alarm. They were later seen cutting the grass in the back garden. Reading the minutes of a staff meeting this person was mentioned in connection with a task required to be done in the home. When asked neither the deputy manager nor the owner, who was doing a carer’s shift at the time, could say whether this person had a staff contract, had had recruitment checks done or had a job description. They did not appear on the rotas. DS0000063929.V295511.R01.S.doc Version 5.2 Page 18 Two files for newly appointed staff were seen. Both contained a job application, records of interview notes, two references and evidence of induction training. One file did not contain evidence that identification documents of the applicant had been seen. The deputy manager contacted the member of staff who was due to do a late shift and requested that they bring the documents with them to be photocopied and placed in their file. The deputy manager said they had been seen previously but no record was made. The documents were seen later when the member of staff reported for duty. Files contained evidence that a variety of training has been taking place such as moving and handling, fire awareness, food hygiene and medication administration training by a local chemist. This was confirmed in discussion with staff members. DS0000063929.V295511.R01.S.doc Version 5.2 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, 35, 36, 38. People who use this service cannot be assured that their health and safety will be protected or that staff are properly supervised however they can expect that their financial interests will be safeguarded. EVIDENCE: There have been a number of changes in management in the last year and there has been previous evidence that the staff team have suffered with the changes. Staff spoken with on the day of inspection said things were better among the senior staff. The deputy manager said they had had a high level of support from the manager during their induction period. Although the manager was taking some personal leave they were in daily telephone contact. Although the personal leave has been longer than 28 days the CSCI have not been notified that the manager has been away. DS0000063929.V295511.R01.S.doc Version 5.2 Page 20 Previous inspections have shown that the system used to manage residents’ personal monies was safe and left an audit trail. Staff said there had been no changes to the system. A number of fire doors were seen to be wedged open including the door between the dining room and kitchen. The corridor near the kitchen that leads to a fire exit was very cluttered with wheelchairs, hoists, a mop and bucket and some stacks of food stores. A recent fire assessment undertaken by Chubb found fire doors wedged open and recommended that self-closure devices be fitted. They also found that the emergency lighting was not maintained and recommended six monthly fire procedures instruction for all staff. The Control of Substances Hazardous to Health (COSHH) folder was seen and only covered laundry products. The Health and Safety folder was a Suffolk Social services document and not appropriate for a small service like the Swallows. When asked for general risk assessments for the home the deputy manager said that the manager had taken them away to work on. Since the inspection CSCI has received copies of a few risk assessments. A certificate from Testelec for testing electrical equipment was seen and showed items such as the washing machine, food processor, table lamps, televisions and electric recliner chairs had all been tested and passed recently. There was evidence in residents’ files that they are consulted on an individual basis in their reviews about their care needs but there was no evidence that the residents as a group were consulted regularly. Staff files seen did not have documented evidence that supervision takes place. The deputy manager said that the manager had intended to give them supervision prior to taking the personal leave but they had not done so so far. Other staff spoken with said they had not had supervision. There was evidence in the refrigerators that the weekend cook had not covered, labelled or dated left over food. The rest of the roast joint that was to be used for a later meal was in a tray of congealed fat, not fully covered. The toilet near the ain entrance of the home is partially carpeted under the washbasin. The piece of carpet has been stuck to the floor but is not adhering properly and poses a risk to residents especially if they are using a walking aid. DS0000063929.V295511.R01.S.doc Version 5.2 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 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 1 10 3 11 2 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 3 X X 1 X 3 2 3 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 1 DS0000063929.V295511.R01.S.doc Version 5.2 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 OP2 Regulation 5 (1) (b) (c) (3) 13 (1) (b) (6) Requirement Each resident must have a contract for the provision of services and facilities from the registered provider. Treatment prescribed for residents must be undertaken, recorded on the care plan and necessary training accessed to ensure it is carried out correctly. Care plans must be reviewed and updated regularly. MAR sheets must be correctly completed to show medication has been administered or the code used to indicate why it was not administered. This is a repeat requirement. PRN medication that gives a choice of dose i.e. one tablet or two must have the number of tablets given recorded each time. This is a repeat requirement. All prescriptions must give clear, unambiguous directions. Residents’ final wishes must be ascertained and recorded in their files. Timescale for action 15/06/06 2. OP8 15/05/06 3. 4. OP8 OP9 15 (2) (b) 13 (2) 15/06/06 15/05/06 5. OP9 13 (2) 15/05/06 6. 7. OP9 OP11 13 (2) 12 (2) (3) 15/05/06 31/07/06 DS0000063929.V295511.R01.S.doc Version 5.2 Page 23 8. OP18 13 (6) 9. OP22 23 (2) (m) 10. OP22 11. OP25 23 (2) (l) (4) (b) (c) (iii) 13 (4) (a) (c) 13 (4) (c) 12 OP31 38 (3) 13. OP27 17 (2) Sch. 4 (7) 14. OP29 19 15. 16. OP36 OP38 18 (2) 13 (6) 17. 18. OP38 OP38 13 (6) 23 (4) (c) (i) 13 (4) (c) The home’s POVA policy must be cross-referenced to the guidelines set out in the Suffolk Interagency Procedures. Arrangements must be made for the storage of pads and dressings in residents’ rooms so they are not on display to anyone entering the room. Equipment stored in the corridor near the kitchen, making access to the fire exit hazardous, must be stored elsewhere not obstructing any fire exits. The hot water supply must be monitored so the water temperature at the point of delivery is not more than 43 degrees centigrade. When the registered manager’s absence exceeds 28 days the Commission must be notified in writing as required by regulation. The duty rota must reflect the hours worked by all members of staff, including the manager, and should identify staff by surnames and grades. Evidence must be provided to CSCI of the status and checks made on the driver/handyman seen working around the home. A programme of staff supervision must be implemented. A Health and Safety folder relating to the service must be compiled as appropriate reference for staff use. This is a repeat requirement. The COSHH folder must reflect all substances used in the home that fall under the regulation. Fire doors that need to remain open during the day must not be wedged but fitted with selfclosure devices. 15/06/06 15/06/06 15/05/06 15/05/06 15/05/06 15/05/06 15/05/06 31/07/06 31/07/06 31/07/06 15/06/06 DS0000063929.V295511.R01.S.doc Version 5.2 Page 24 19. 20. 21. OP38 OP38 OP38 23 (4) (c) (i) 13 (4) (c) 13 (4) (c) 13 (4) (a) The requirements made by the Chubb fire assessment must be implemented. Left over food must be stored correctly, labelled and dated. The potential trip hazard in the toilet near the entrance must be made good. 31/07/06 15/05/06 15/05/06 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. Refer to Standard OP15 Good Practice Recommendations The jugs used to supply drinks at mealtimes should not be measuring jugs and should be free from staining. DS0000063929.V295511.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 DS0000063929.V295511.R01.S.doc Version 5.2 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. 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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