CARE HOMES FOR OLDER PEOPLE
The Fairway Green Lane Highlands Oxhey Hertfordshire WD19 4LX Lead Inspector
Mr Tom Cooper Unannounced Inspection 27th January 2006 12:20 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 Fairway DS0000019568.V274779.R01.S.doc Version 5.1 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 Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Fairway Address Green Lane Highlands Oxhey Hertfordshire WD19 4LX 01923 221345 01923 209997 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) www.quantumcare.co.uk Quantum Care Limited James Antwi Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45), of places Physical disability over 65 years of age (45) The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: The Fairway was originally a purpose-built Hertfordshire County Council care home for the elderly, subsequently acquired in 1992 and refurbished by Quantum Care Limited, the voluntary organisation that is the provider with the largest number of care homes in Hertfordshire. The home provides accommodation and care for older people, including individuals with varying degrees of dementia, in four separate units on three floors. Each unit has a small kitchen where residents and their relatives can make drinks and snacks. The home stands in pleasant grounds by a main road with the entrance in a side road in Oxhey, close to Watford town centre. Local shops are within walking distance. There is adequate car parking space in front of the building. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The last inspection was carried out on 10th October 2005. The inspection took place over one afternoon/early evening on a weekday. The main purpose of the inspection was to evaluate the service users’ experience of living at the home and to follow up the requirements made at the last inspection. Discussions were held with a large number of service users and members of staff on duty including two care team managers, and several care assistants. Documentation examined included ten service users’ care plans, some staff supervision and training records, the complaints procedure, medication records, proprietor’s representative’s visit reports and residents’ meeting records. Staff were observed working with service users and all four units were visited, including a number of residents’ bedrooms and bathrooms as well as the main kitchen. However a formal tour of the premises was not conducted. The inspection indicated that the home was running smoothly, with mostly contented residents cared for by well trained and highly motivated staff. Three statutory requirements have been made, two restated from the last inspection have been restated due to non-compliance and a new one in respect of risk assessment control measures. What the service does well:
The home has good information available to prospective and current residents about the aims of the home and the service promised. Care plan documentation seen made out in the standard Quantum Care format was adequate, conveying a fair level of detail of the individual needs of service users and the actions determined to meet them. The company policy of staff making monthly reviews of care plans was being followed so that the information contained remained up to date. Service users who expressed opinions said that staff were mostly very friendly and caring and tried hard to look after them in the way they would wish and this was supported by the inspector’s observations during the inspection. The home employs an activities coordinator who takes the lead in providing a range of meaningful activities, based on the known interests and preferences of service users. Many service users asked expressed no interest in participating in events taking place, while others commented positively on the
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 6 scale and scope of activities available. For example numerous appropriate seasonal social events had been organised over the Christmas period, including entertainment brought in from outside that many residents enjoyed. Many service users praised the food provided, which the chef prepares from the well balanced and nutritious four-week rotating menu. They confirmed that good alternative meal options were always available. Staff are well trained in sensitively supporting service users who need help with eating, as observed at lunch and tea on the day of the inspection. The main kitchen is clean and well organised. The home has an adequate complaint procedure, although no complaints had been recorded since 2004. Some residents said they were aware of the procedure should they wish to complain. Staff have a good understanding of the company’s whistleblowing policy and their responsibilities under it in any situations of potential or actual abuse or neglect. Service users are also protected by clear procedures and safe practices for the handling of medication. The home provides a suitable environment for elderly people who may have restricted mobility and dementia and is maintained and decorated to a high standard. The four-unit lay out creates smallish living spaces that retain some domestic characteristics and service users are able to personalise their bedrooms to suit. The communal spaces are well appointed. The home is effectively managed, although there are vacancies in the senior team that should be filled. Care staff are regularly supervised and said they felt well supported. The home has a good quality monitoring system in place that includes actively seeking the views of service users and other interested parties. However, although staff stated that a senior Quantum Care executive made regular monthly monitoring visits to the home, the subsequent reports had not been sent to the manager (see below). What has improved since the last inspection? What they could do better:
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 7 Two requirements remain outstanding from the last inspection. Although the Care Team Managers on duty confirmed that monthly monitoring visits by a senior Quantum Care executive had taken place, the subsequent reports on the conduct of the home had not been sent to the manager since August 2005. Copies of these reports must be sent to the registered manager of the home to provide a record of the findings, any actions to be taken and to comply with Regulation 26. The requirement to review the practice of placing kylie sheets on lounge furniture seats had evidently been ignored as numerous examples were noted around the building. Such overt signs that incontinence is expected are considered to detract from service users’ dignity therefore it is required that an alternative, more subtle means of protecting seat covers be found. Two examples of completed formal risk assessments were found that indicated the service was at risk of developing a pressure sore but no control measures were listed as action points for staff. All identified risks should have clearly documented control measures to ensure they are effectively managed to minimise the potential negative outcomes. The manager should attempt to recruit suitable individuals to fill the current vacancies in the senior staff team to reduce the pressure on the care team managers. 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 Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 The home has a statement of purpose and service user’s guide containing the required information so that prospective service users can make an informed choice about whether to move in. Service users are assessed prior to their admission to ensure that the home will be able to meet their needs. Prospective service users and/or their relatives are able to visit the home to access the quality, facilities and suitability of the home prior to making a decision on whether it would suit them. EVIDENCE: The home has a statement of purpose and a service user’s guide that contain the required details about the philosophy of care and operation of the home. These documents are available to all prospective service users and their representatives. Pre-admission assessment information was present in all care documentation examined. Social services funded service users are assessed through the ‘care management’ arrangements and the home receives a copy of the assessment papers and hospital discharge letter if applicable. In addition a
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 10 senior member of staff conducts an independent pre-admission assessment on behalf of the home to establish that the home would be suitable. Prospective service users are invited to look around the home. Normally, visits take place with relatives. Initial admissions are subject to a mutually agreed trial period that can be extended if necessary. At the end of the trial period the placement is confirmed if all parties agree that it is appropriate. This period allows staff at the home to assess the individual’s needs further and devise a detailed care plan. Some residents spoken to stated that they had visited the home or their families had done so on their behalf prior to admission. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Care plans are in place documenting the individual health, personal and social care needs of each service user. Staff monitor and record service user’s condition and health and act to ensure that their health needs are met. However care should be taken to record control measures on all pressure sore risk assessments. The home has robust medication procedures that ensure medicines are handled and administered safely. Service users feel that staff treat them with respect and promote their privacy. However the use of kylie sheets as seat protectors is unsightly and detracts from their dignity. EVIDENCE: The Quantum Care care plan format was in use. Ten care plans examined all contained clear details of the respective individuals’ needs, including the action to be taken by staff to meet them. Some care plans had been signed by the residents. Information regarding visits to outside health professionals was recorded in the daily notes. The home’s policy is to review and update care
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 12 plans on a monthly basis and this had been recorded. The case records showed that residents had access to doctors, specialist community nurses, chiropodists, opticians and dentists etc. Risk assessments were in place for a wide range of factors including moving and handling, falls, incontinence, pressure sores and so on. However in two cases there were no control measures noted on pressure sore risk assessment documents even though the service users were rated at risk of developing them. These must always be recorded so that staff have clear instructions to follow (see requirements). On all the care plans there were good details of individual needs as well as useful notes of particular preferences regarding for example rising/retiring times, food, activities, social habits and simple behavioural guidelines. The service users appeared well cared for and were physically well presented, wearing clean and appropriate clothes and with generally tidy hair and fingernails. Many of the service users spoken with confirmed that staff were very caring and supportive and encouraged them to make decisions for themselves, whilst offering assistance as appropriate. The home has appropriate policies and procedures covering maintaining dignity and respect for service users. Staff/resident interaction observed during the inspection was very positive, with staff showing great respect and empathy and conversing freely with residents. Service users said that staff always knocked and waited at their bedroom doors before entering and this was observed in practice. Unfortunately, although staff considered them effective, the obvious placing of kylie sheets as incontinence barriers on lounge armchairs detracts from the dignity of the environment as it indicates that incontinence is expected. For this reason more subtle alternative ways of protecting seats must be found and the requirement made in the last inspection report has been repeated. Medication storage and records were checked in one unit and found to be satisfactory. Storage of medicines was secure and well organised in a locked cupboard. No recording errors were found on the medication administration record sheets. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 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 - 15 Residents have the opportunity to lead the lifestyles they choose. They can participate in a range of stimulating activities that are organised for them by staff. Visitors are made welcome and staff support and encourage service users to maintain contact with families, friends and the community. Where possible residents are encouraged to be as independent as possible and are able to make decisions for themselves. The four week rolling menu offers a well balanced and varied diet that service users enjoy. Any specialist diets are catered for appropriately. EVIDENCE: The home employs an activities coordinator to provide a range of meaningful activities. A calendar of events planned was on display. Service users spoken with commented that they were satisfied with the range and frequency of activities on offer. They were able to choose to participate as they preferred. The home encourages volunteers and holds events during the summer months and over the Christmas period to raise money for the amenity fund. Recently carol singers and outside entertainers had visited the home and performed for
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 14 the residents. Occasional outings for groups in the home’s minibus are arranged. The care team manager confirmed that residents’ meetings continued to be held regularly and the minutes of two such meetings since the last inspection were on file. Residents are able to bring personal possessions with them into the home and lists are held on their files. Visitors are welcome at any reasonable time. A visiting relative said that he was always made to feel welcome and several residents said they appreciated the open approach of the manager and staff. The home has a four week rolling menu that provides a well balanced, varied and nutritious diet. Most service users spoken with praised the quality and variety of the food provided and said they always had a choice of alternative meals if necessary. The chef knows which residents have special dietary needs and these are recorded and catered for appropriately. At lunch and tea staff were observed discreetly helping residents who had difficulty feeding themselves, giving them individual attention and allowing plenty of time to finish. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 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 Information on how to make a complaint is available and service users and their relatives should feel confident that any complaint they make will be listened to and acted upon by the manager. Adult protection policies and procedures are in place that should ensure the safety of service users. EVIDENCE: Quantum Care has an adequate complaints procedure and information on how to make a complaint is available to service users, relatives and involved professionals in the service user’s guide and elsewhere. Staff spoken with had a good understanding of the principles involved in dealing with a complaint. Many of the residents had dementia and were unable to comment however those who did said they knew who to approach if unhappy about any aspect of life in the home. No formal complaints had been received by the home since 2004 therefore it was not possible to verify that the company’s procedure was being correctly followed. However the high levels of satisfaction reported by service users supported the care team manager’s explanation of the home’s preferred approach of attempting to resolve any grumbles raised at an early stage before the formal complaints procedure is invoked. Quantum Care also has a whistleblowing policy that is available to staff. Individual staff spoken with were aware of this policy and had a fair grasp of their responsibilities under it. A copy of the Hertfordshire inter agency adult protection procedure is kept in the home. There are also internal policies on adult protection and evidence was presented of recent anti-abuse training
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 16 given to some care staff. The topic is covered in the induction programme for staff and also forms part of the NVQ2 course undertaken by many staff. Although not checked at this inspection, it has previously been established that the home has a good system for safekeeping residents’ money, with a clear accounting process to ensure accurate records are maintained. Service users have been provided with lockable storage facilities where appropriate. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 17 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 & 26 The building and grounds provide a safe, well maintained and comfortable environment for the service users. The four separate units provide smallish domestic living areas that are homely and suit the needs of people with restricted mobility and confusion. A high standard of cleanliness was evident enabling service users to enjoy pleasant and hygienic living spaces. EVIDENCE: The home shares the services of a handyperson with other Quantum Care homes and this ensures that the premises remain in good order. There is a rolling plan of maintenance and redecoration and minor repairs are carried out promptly. As a result the premises are well maintained and decorated, with each unit arranged to provide a reasonably homely living environment that is suitable for meeting the aim of the home to care for elderly service users who may have restricted mobility, poor eyesight and hearing and the confusion associated with dementia. The building is bright and airy, corridors are
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 18 relatively wide and communal areas are sufficiently spacious for residents to move around in safely. The passenger lift serves all three floors. Indoor communal spaces are decorated and lit in domestic styles, with relaxing and cheerful colour schemes. The grounds are fully accessible, although there are some steep slopes where service users would need supervision. The home has a hard wired fire detection and alarm system and a staff alert call system, with call points and switches available to all residents. Service users said that staff generally responded quickly to call bell alerts. All bedrooms are singles and those seen had been personalised to suit the individual occupants. All areas seen were clean, tidy and fresh smelling. The laundry is suitably located and well equipped to deal with the workload generated by forty five residents. Staff are aware of and follow good infection control practices. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 19 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, 29 & 30 Staffing levels are adequate to meet service users’ needs and fulfil the aims of the home. The home has rigorous recruitment and staff selection policies and procedures that protect the interests of service users. The home’s induction, supervision and ongoing training policies ensure that staff are adequately trained and competent to do their jobs. EVIDENCE: On the day of the inspection there were seven care staff on duty plus a care team manager, the administrator, the chef and a kitchen assistant as well as ancillary staff to care for the 40 residents present in the home. The care team manager and other staff confirmed that this was the typical picture. The staff rota was available as a record to demonstrate day to day staff numbers. Staff said they felt able to carry out their duties adequately and service users who commented similarly felt that levels were sufficient. One area that should be strengthened is the senior team as there was no deputy manager in post and there were two other care manager vacancies. This meant the senior team was being spread rather thin. The manager should actively seek to recruit suitable personnel to these posts as soon as possible (see recommendations). Quantum Care provides staff with excellent relevant training opportunities. The home has an annual training schedule and all staff are expected to be involved.
The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 20 Recent courses staff had attended had included moving and handling, health and safety, food hygiene, fire safety and dementia. The company has also encouraged and supported staff to undertake NVQ training at levels 2 or 3 and has NVQ assessors on the team. Staff files were not checked on this occasion but it has previously been established that the home operates sound recruitment and selection procedures, ensuring that all staff are properly vetted and are fit to work with vulnerable adults. The home has a thorough induction programme for new staff. One recently recruited care worker described in detail the elements of the induction she had received, explaining that she was working her way through the foundation training programme. This programme is in line with the National Training Organisation’s guidelines and ensures that staff are capable of working to good care practice standards that fulfil the aims of the home. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 21 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): 32, 33, 36, 37 & 38 Staff work well together to deliver the service promised in the home’s statement of purpose. This is reinforced by the company’s quality monitoring system that is designed to ensure that the home is run in the best interests of the service users. Staff feel adequately supervised and supported by more senior staff and this ensures a consistent standard of care delivery to service users. Most of the records required by regulation are maintained satisfactorily. However staff must include control measures on all risk assessments and the proprietor’s representative must send copies of the monthly monitoring reports on the conduct of the home to the manager. The home has a health and safety policy and staff follow safe work practices to ensure the establishment is a safe place in which to live and work. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 22 EVIDENCE: Feedback from the service users and staff spoken with indicated that the management approach of the senior team was positive, open and communicative. Staff felt that strong leadership was provided in the home and service users were aware of the presence and influence of senior staff. The home annually canvasses the views of interested parties including service users, relatives and others by means of questionnaires sent out in October. The results are analysed and published and used to inform planning in the home. Records showed that regular residents’ meetings had taken place. Staff spoken with said they felt well supported by senior colleagues and had regular individual supervision. Records were available to demonstrate this. Most of the records seen were maintained satisfactorily. However, as reported earlier in this report, the relevant file contained no monitoring reports form the proprietor’s representative dated after August 2005 and control measures had not been noted on pressure care risk assessments (see requirements). All areas seen during the inspection appeared safe and free from hazards. All COSHH items were locked away. Equipment checked such as fire extinguishers had been serviced within the last year. Fridge and freezer temperatures had been recorded daily in the main kitchen. Medication was stored safely. Soiled and clinical waste was being disposed of correctly. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 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 3 3 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X X 3 2 3 The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? 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 OP8 Regulation 12(1) 13(4)(c) 15(1) 2. OP10 12(4)(a) Requirement All identified risks should have clearly documented control measures to ensure they are effectively managed to minimise the potential negative outcomes. This particularly applies to pressure sore risk assessments. To ensure that service users’ dignity is preserved an alternative means of protecting seat covers must be found instead of placing kylie sheets on lounge furniture. Previous requirement restated. Timescale for action 28/02/06 31/03/06 3. OP33 OP37 26(4)(c) Copies of the proprietor’s 28/02/06 representative’s monthly reports on the conduct of the home must be sent to the registered manager. Previous requirement restated. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 25 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 OP27 Good Practice Recommendations The manager should recruit suitable individuals to fill the current vacancies in the senior staff team to reduce the pressure on the care team managers. The Fairway DS0000019568.V274779.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Fairway DS0000019568.V274779.R01.S.doc Version 5.1 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. 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!
