Inspection on 25/07/06 for The Close

This inspection was carried out on 25th July 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

The Close 19/06/09

The Close 23/07/08

The Close 24/07/07

The Close 29/09/05

The Close 26/04/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Close 53 Lynn Road Snettisham Kings Lynn Norfolk PE31 7PT Lead Inspector Lella Andrews Unannounced Inspection 26th July 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 The Close DS0000064311.V306045.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. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Close Address 53 Lynn Road Snettisham Kings Lynn Norfolk PE31 7PT 01485 540041 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) Norfolk Care Ltd Position Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2005 Brief Description of the Service: The Close is a care home providing personal care and accommodation for twenty-three older people. The home is privately owned by Norfolk Care Ltd. The home is located in the village of Snettisham. The coastal town of Hunstanton is approximately five miles away and King’s Lynn approximately ten miles. The Close is a large detached property and provides accommodation on the ground and first floors for up to twenty-three elderly people. Seventeen of the bedrooms are single and two are double. Nine of the bedrooms have en-suite facilities. Access to the first floor is gained by one of two staircases, one with a stair lift, or a passenger lift. There is a pleasant, well-maintained garden with lawns, trees and shrubs, which had a path all around the home, enabling residents to walk safely outside. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection process includes reviewing the information received by the Commission about the service and a visit to the Home which was carried out between 9.30am to 5pm on Tuesday 25th July 2006. During the visit discussions were held with residents, staff, visitors, district nurse and the proprietor. Records were seen and a tour of the premises was undertaken. The pre-inspection questionnaire was not returned. The comment cards sent to the Home were not distributed by the proprietor and so no completed comment cards were returned to the Commission. The Home is owned by a company, and one of the Directors is currently managing both this Home and the other Home owned by the company. There is a need for the company to employ a manager at this Home who will become registered with the Commission. There are currently 20 residents living at the Home. The fees range from £338.00 to £400.00 per week. What the service does well: What has improved since the last inspection? A system of formal supervision has been introduced for the staff which enable them to have the opportunity to discuss their work and any training that they need. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 6 A quality assurance system has been decided upon by the proprietor and will be implemented shortly. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Close DS0000064311.V306045.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 The Close DS0000064311.V306045.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): 1 and 3. The Home does not provide intermediate care. Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. There is a lack of written information available about the service which prospective residents and their families can refer to. Assessments are undertaken prior to a resident moving into the Home. EVIDENCE: The Statement of Purpose has been reviewed and a draft was seen on the computer. Service User guide not yet updated. Previous requirement repeated. The form used to carry out pre admissions assessments has been updated and contains the necessary information on which a decision can be based about whether the Home can meet the needs of the resident. Staff said that they The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 9 receive good information about the needs of prospective residents prior to them moving into the Home. The Close DS0000064311.V306045.R01.S.doc Version 5.2 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 and 11 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The quality of the care plans is variable with some containing detailed information and others containing out of date information. Care staff provide care in a kind and respectful manner. Staff liase appropriately with health professionals. In general, medication is well managed but there is a need to update some aspects of the procedures. There is a need for locks to be fitted to bathroom/toilet doors to improve privacy for the residents. Residents are looked after well when at the end of their life. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three of the care plans were seen. One of these has been updated on to a new format which is much more detailed and easier for staff to access. The new format contains several individual risk assessments eg. Moving and handling, mental health, falls, pressure care. There is also information about the residents individual preferences, such as preferred name, food and drink choices which helps the staff to provide personalised care to residents, even those who may find communication more difficult. However, the process of updating the care plans is not any further forward than it was during the last Inspection (April 06) and the fact that the Home does not have a Manager who can undertake this work has hindered this process. As the care plans are all going to be transferred to the new format there has been little, if any, reviewing or updating taking place on a regular basis. Therefore, one of the care plans seen bears little resemblance to the actual care required, and being provided to, the resident concerned as their needs have greatly increased recently. Another care plan contains no information about a particular health need that a resident has and the medical treatment which the proprietor said they had received. It is required that the care plans are reviewed and updated on a regular basis and following any changes in residents needs. It is also required that the care plans contain detailed information abut the residents health needs. Some of the care plans now have a form which is signed by the resident/relatives to confirm that they are aware of the content of their care plan. This work has been done following a previous recommendation. The staff are aware of the care plans but not all staff feel that they have had time to read them all. Staff keep daily notes for each resident and these were seen for the three residents whose care plans were seen. The quality of these is variable, with some being quite detailed and other entries fairly sparse. The staff use the daily notes, rather than the care plans as the records which inform them of the ways in which care should be provided. The daily notes include advice given by health professionals. Information obtained from the visiting District Nurse provides evidence that the proprietor and staff work well with the nursing staff and that any recommendations for care are followed. Communication has improved and there is now a communication book for use between the nursing and the care staff. The nurse feels that health professionals are contacted appropriately. Poor moving and handling practice was seen during the visit with residents using wheelchairs without cushions or footrests. The majority of the staff have The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 12 received moving and handling training. It is required that wheelchairs are fitted with cushions and footplates. Discussions with three members of staff provided evidence that staff are aware of the importance of respecting the privacy and dignity of the residents. The residents said that staff are respectful and kind. Staff were heard to speak kindly to the residents and to take time to explain things to them. None of the toilets or bathrooms have locks on the doors and a requirement is made for this to be rectified. The administration of medication was observed and the records/trolley inspected. Staff receive appropriate training to carry out the administration of medication and the administration was carried out and recorded appropriately. The medication procedure is in need of reviewing so that it is clearer (currently contains words such as Registered General Carer) and contains information about the procedure following an administration error and a clear policy about the use of homely remedies. A requirement is made about this. The minutes of the most recent staff meeting shows that some recent issues with medication have been identified and addressed by the proprietor with the staff team. Staff feel that they have time to spend with residents when they are very ill or are dying. Two relatives said that they could not speak highly enough of the care that their relative is receiving during her last weeks. They said that the staff have a good understanding of the needs of the resident and that they make extra efforts to ensure that the resident is comfortable and has someone with them the majority of the time. Appropriate support from health professionals has been sought and medication administered for additional pain relief. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. A range of activities are provided to the residents throughout the week Relatives and friends are encouraged to visit and are made to feel welcome Residents enjoy their meals and individual dietary needs are taken into consideration. EVIDENCE: The activities programme for the Home show that there are regular activities arranged in the Home during the week including playing cards, music and communion as well as a programme of events taking place over the summer, including garden party, trips to the theatre and other areas of interest locally. A small group of residents were taking part in a game of cards with a volunteer during the afternoon of the visit to the Home. Residents said that they feel that there are plenty of opportunities for them to join in with activities if they wish to. Visits from the local vicar and the church choir take place on a regular basis and visits from other religious bodies can be arranged as residents request this. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 14 There were several visitors to the Home during the time of the visit and some spoke to the Inspector. They all spoke highly of the staff and the proprietor, saying that they are always made to feel welcome and that they are able to visit at any time they wish to. Two relatives said that they had been able to spend long periods of time with their relative when they had been very unwell and that meals and support were provided to them by the staff. The bedrooms show that residents have been encouraged to bring in personal items with them and the proprietor understands the importance of this. The staff/proprietor are not responsible for money belonging to the residents and this is made clear to prospective residents before they move to the Home. The residents said that they enjoy their meals and that they are offered a choice. The cook was on holiday on the day of the visit and so one of the care staff was doing the cooking. The residents were offered a choice of main meal and other alternatives were seen to be provided to any residents who did not like either of the choices or who required a special diet. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The Home has a complaints procedure of which the residents are aware Training needs to be provided to all staff and the procedure needs to be updated to further improve the protection provided to residents. EVIDENCE: The Proprietor said that there have been no complaints but that she is aware of the need to maintain a record if one is made. Residents said that they would talk to the staff or the proprietor if they were not happy with anything but no examples were given of complaints having been made. The complaints procedure is on display in the Home. Relatives were aware of the complaints procedure. The majority of the staff have completed some form of training with regard to the protection of vulnerable adults and it is required that all staff attend formal training about this subject. It is also required that the procedure relating to allegations of abuse are updated to reflect the correct procedure. Staff said that they are confident that any concerns about poor practice or abuse would be dealt with appropriately by the proprietor. The proprietor said that no allegations of abuse have been made at the Home since she has owned it. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The Home meets the needs of the residents. There are some requirements and recommendations but the proprietors are aware of these and have plans to address them. EVIDENCE: A tour of the Home was carried out with the Proprietor. Only a selection of bedrooms were seen but all bathrooms and communal areas were seen. The proprietor has an ongoing maintenance and redecoration plan which has been ongoing since they bought the Home a year ago. One of the two lounges was not in use on the day of the visit as it is being redecorated. The other lounge and the conservatory are furnished in a homely way and the residents said that they like to spend time there. The gardens have recently received attention and are a pleasant place for residents to sit. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 17 Some of the bedrooms have been redecorated and some are still in need of redecoration. One of the rooms has some damage to the ceiling following a flood and whilst the original damage has been fixed it is required that this bedroom is redecorated as soon as is practical. It is also required that window restrictors are fitted to all windows on the first floor. The bedrooms in the ground floor extension are particularly attractive with ensuite shower/toilet and patio doors to the front garden. The stair carpet on the main staircase has a small hole and some wear and tear and it is required that this is repaired. The previous requirement date of June 2006 has not been met. It is required that all bathrooms and toilets have locks fitted to ensure the privacy for residents using them. The bathrooms and toilets would all benefit from redecoration. The temperature of the hot water in one of the bathrooms was measured and was slightly higher than the recommended 43 degrees. The proprietor said that hot water regulators are fitted to the baths and it is recommended that these are all tested to ensure that they are working appropriately. The staff are encouraged to check the temperature of the bath prior to residents using it. The recommendation to put residents names/room numbers on the bedroom doors is repeated in this report. This will assist the residents to find their rooms and also aids staff in the event of a fire. The Home has a laundry room sited on the ground floor and the care staff are responsible for the laundry throughout the day. The Home has gloves and aprons situated around the Home for use by staff. It was noted that disinfectant was left in each of the bathrooms and it is required that this is stored securely. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The staffing levels in the Home are adequate to meet the needs of the residents. Staff training is improving with the majority of staff receiving appropriate training. There is a need to ensure that all information relating to the recruitment of staff is obtained prior to staff starting work to ensure the protection of the residents. EVIDENCE: The rotas confirm the staffs information that the usual staffing ratio is for three care staff on duty in the morning, two in the afternoon/evening and two waking night staff. In addition to this there are domestic staff on duty six days per week and a cook on duty seven days per week. There is also a teatime cook on duty five days per week. Discussions with staff and residents show that the staffing is adequate to meet the needs of the residents. However, there is little time for staff to spend additional time with residents to have a chat. The provision of organised activities is a necessity as the staff would not have time to arrange and carry out activities on a regular basis. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 19 The provision of a teatime cook is a positive one as this means that the care staff are free to spend the time in the provision of care rather than in the kitchen. It is required that staff are employed in the kitchen seven days a week. It is required that all staff working in the kitchen receives appropriate training. It is recommended that domestic staff be provided seven days per week. The current numbers of staff having achieved NVQ Level 2 does not meet the standard of 50 but the proprietor advised that five staff are due to start this in September and some are due to finish shortly and so the Home will then meet the standard. Training has been provided in other subjects such as moving and handling, protection of vulnerable adults and fire safety since the proprietor took over the Home a year ago. New staff receive induction training from the proprietor and then attend college to undertake formal training as per Skills for Care induction standards. The induction training provided in the Home needs to be more organised to ensure that the staff receive appropriate information in a timely way. Two of the recruitment files were seen. One of these contained the necessary information but the second did not contain an up to date CRB disclosure, just a copy of one obtained by the individual in 2003. It is required that the information listed in Schedule Two of the Care Homes Regulations is kept for all members of staff. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. There is a need for a manager to be employed at the Home so that outstanding management issues can be dealt with effectively. The views of the residents are sought in an informal, inconsistent way but the development of the proprietors formal quality assurance process should improve this situation. EVIDENCE: The Home does not have a registered manager. The proprietor is currently managing both this Home and the other Home that company owns. The proprietor has employed an acting manager who is undertaking some of the administration relating to records. The acting Manager has no previous The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 21 experience in care work. The acting Manager was not on duty on the day of the visit and so no discussions were held with them. The previous requirement for an application for registration to be received from a manager by June 2006 has not been met. This requirement is repeated in this report. Many of the areas in which the NMS are not fully met (highlighted in this report) are likely to be due to the lack of management in the Home. The proprietor is working hard to manage both homes but it is not possible to do this effectively. The proprietor has put together a quality assurance process which she has started to implement. As the Home is owned by an organisation there is a need for monthly visits to be carried out as per Regulation 26. These are not currently being carried out although the proprietor is in the Home several days per week. It is required that Regulation 26 visits are carried out and that the reports are sent to the Commission. The Proprietor said that the views of the residents and relatives are sought through face to face conversations and that their views have also been sought through the use of a questionnaire. Whilst this is positive there is still a need to implement the more formal processes that the proprietor has planned. The proprietor said that the Home does not look after money for any of the residents and that residents are made aware of this prior to moving to the Home. There has been an improvement in the formal supervision provided to staff since the last report. The proprietor has implemented a system of supervision which includes observed practice, 1:1 meetings and an annual appraisal. Some staff have already received an appraisal and the records show that these are detailed and lead to development plans for individual staff. However, the supervisions should include feedback about actual working practices and therefore should have picked up the issue about poor moving and handling practice. The Home has health and safety policies and procedures. The majority of staff have received fire and moving and handling training. The proprietor is in the process of reviewing which staff need to have updates of other mandatory training. Records seen show that the hoists have been serviced recently but the proprietor was unable to find the service certificate for the lift. The inspector was later notified that the lift was due to be serviced on the 1st August 2006. The records relating to fire safety were seen. These show that the fire safety equipment has been serviced recently. The fire risk assessment was carried out in November 2004 prior to the proprietors taking over the Home and it is recommended that this is reviewed and updated. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 22 It is recommended that regular fire drills take place. The proprietor feels that it is intrusive for the residents but there are ways of enabling staff to have the practice without involving the residents. It is required that weekly fire alarm checks are carried out with records kept of these. It is required that the towel rail/radiator in the bathroom on the first floor is covered to ensure that residents are not scalded on it. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 X 2 The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 (1) Requirement The registered person must ensure that an updated copy of the statement of purpose and service User guide is forwarded to the Commission for Social Care Inspection and copies given to all the residents. The previous date of 10/06/06 was not met. It is required that the care plans and risk assessments are reviewed and updated so that they contain clear guidance about how to meet residents needs. It is required that the care plans contain details about the residents health needs. It is required that the wheelchairs have cushions and footrests and are used appropriately. It is required that the bathrooms and toilets doors have locks on. It is required that the medication procedure is clear and that it contains information about the procedure to follow in the event of an error in administration. It DS0000064311.V306045.R01.S.doc Timescale for action 30/09/06 2 YA6 15 31/10/06 3 4 YA8 YA8 15 13 (5) 31/10/06 31/08/06 5 6 YA10 YA9 12 (4) 13 (2) 31/08/06 30/09/06 The Close Version 5.2 Page 25 7 YA18 13 (6) 8 YA18 13 (6) 9 OP19 13 (4) 10 11 12 13 14 15 16 17 18 19 OP19 OP19 OP26 OP27 OP29 OP30 OP31 OP33 YA38 YA38 13 (4) 23 (2b) 13 (4) 18 (1) 19 (4) 18 (1) 8 (1b) 26 23 (4) 13 (4) must also contain clear guidance about homely remedies. It is required that all staff receive training about the protection of vulnerable adults (POVA). It is required that the POVA procedure reflects the procedure in Norfolk following an allegation of abuse. It is required that the tear on the stair carpet is repaired. The previous date of 10/06/06 was not met. It is required that window restrictors are fitted to the first floor windows. It is required that bedroom 13 is redecorated. It is required that cleaning materials are stored securely. It is required that kitchen staff are employed for the tea time period seven days a week. It is required that the information listed in Schedule 2 is kept for all members of staff. It is required that all staff who work in the kitchen receive appropriate training. It is required that the Home has a registered manager. It is required that monthly visits are carried out as per Regulation 26. It is required that weekly fire alarm tests are carried out. It is required that the towel rail/radiator in the bathroom is covered. 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/08/06 30/09/06 31/08/06 31/10/06 31/10/06 31/08/06 31/08/06 30/09/06 The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP19 YA19 YA27 YA38 YA38 Good Practice Recommendations It is recommended that the resident’s name and room number are displayed on the bedroom doors. It is recommended that the hot water regulators are checked to ensure that they are working effectively. It is recommended that a member of domestic staff is on duty every day. It is recommended that the fire risk assessment is reviewed and updated. It is recommended that regular fire drills are carried out. The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 The Close DS0000064311.V306045.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!