Inspection on 25/05/06 for The Firs

This inspection was carried out on 25th 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.

Other inspections for this house

The Firs 12/06/08

The Firs 23/05/07

The Firs 09/02/05

The Firs 10/09/04

The Firs 05/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Firs, The 90 Glasshouse Hill Codnor Ripley Derbyshire Derbyshire DE5 9QT Lead Inspector Anthony Barker Key Unannounced Inspection 25th May 2006 10:55 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 Firs, The DS0000002116.V294446.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. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Firs, The Address 90 Glasshouse Hill Codnor Ripley Derbyshire Derbyshire DE5 9QT 01773 743810 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) Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 30 places for OP 2 places for younger PD aged 50 and over included in above total Date of last inspection 27th March 2006 Brief Description of the Service: The Firs is situated in the village of Codnor. It is a converted house with extensions. The Home provides 30 beds for older people needing nursing care. There are 24 single rooms, of which 4 have en suite facilities, and an additional 3 shared rooms. There is provision for 2 people with physical disabilities, aged 50 years or over, included within the 30. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 9.25 hours over two days in May 2006 and was a key unannounced inspection. The last inspection took place in March 2006 and was unannounced. Four residents, the Acting Manager, the General Manager and two other members of staff were spoken to and records were inspected. There was also a tour of the premises. Two residents were case tracked so as to determine the quality of service from their perspective and two further residents were spoken to. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Medication Administration Record (MAR) sheets must include a recorded signature and date when the medication is received. A record must be Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 6 maintained within the Home of the outcome of any investigation into complaints made about the Home. The Home must have an appropriate policy on Adult Protection and all allegations of abuse must be followed up promptly in line with local protocol and the action taken recorded. One carpet must be repaired to prevent trips. Staff must be provided with further mandatory training and Fire training must be provided twice a year for night staff. The safety of the resident making sole use of the Home’s ‘smoking room’ must be addressed. 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. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 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 Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 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): 1,2,3 & 6 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Prospective residents did not have all the information they needed to make an informed choice about where to live. However, they had been provided with a statement of terms and conditions of residence and their needs were being fully assessed before admission. The Home was not providing intermediate care. EVIDENCE: The Homes Statement of Purpose still did not cover the details outlined in Standard 1.1 regarding the Homes physical environment standards, except regarding bedrooms. The General Manager stated that all residents, or their representatives, had been provided with a copy of their statement of terms and conditions of residence. Additionally, invoices had the Homes Terms and Conditions printed on their rear. The daughter of one case-tracked resident confirmed that she had been provided with a copy of their statement of terms and conditions. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 9 The files of the two case-tracked residents included assessments and care plans completed prior to their admission. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 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 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs were well set out in individual care plans although they were not being fully protected by the Home’s procedures for dealing with medicines. Residents felt they were being treated with respect and their right to privacy was upheld. EVIDENCE: The care plans and risk assessments of the case-tracked residents were examined and were found to be of a very good standard. They were comprehensive and daily progress sheets were well completed and reflected care plans. Improvements to the care planning system included the addition of new sets of records and much improved recording practices. There was a system in place for recording monthly care plan reviews by a nurse and monthly quality checks by the Manager – these were mainly up to date. All privately-funded residents, as well as care managed residents, had had formal care plan reviews, the Acting Manager reported. The formal care plan review meetings for privately-funded residents were including an Age Concern Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 11 advocate who, the Acting Manager said, was making constructive recommendations. Appropriately recorded health risk assessments were found on residents’ care plans. Bed rails assessment forms, and risk assessments/risk management plans regarding a resident falling out of bed, were also seen. A bed rails Risk Assessment Consent Form had the resident’s relative’s signature but there was no evidence of a multi-disciplinary decision/agreement. The Acting Manager and General Manager confirmed that this did not occur and the latter spoke of the difficulty she had had in involving external professionals in the assessment for bed rails. The same lack of multi-disciplinary involvement applied to the assessment for ‘wanderer mats’ beside residents’ beds. The storage of medicines and medicine recording practices were examined. These were found to be satisfactory except that two items of medication received, recorded on one case-tracked resident’s Medication Administration Record (MAR) sheet, had no signature or date against them. Also, some other MAR sheets had no recorded signature or date when the medication was received. A daily medication audit sheet and weekly managers medication audit sheet were seen. Cross-referencing of MAR sheets and morning blister packs, for one case-tracked resident, indicated no anomalies. The Acting Manager reported that the Home had reviewed its ‘blanket’ policy of insisting that staff must attend all baths taken by residents, so addressing residents’ need for privacy and dignity if requested. Plans were in place to fit emergency call system pull cords beside baths so that residents who could safely bath alone could call for help if necessary. The Acting Manager said there were currently no residents who would not be at risk if left alone. Two case-tracked residents and their respective daughters were spoken to. It was clear that they felt they were treated with respect and that their privacy needs were adequately met. One resident had been offered a key to her bedroom but had declined. Her care plan indicated how important her physical appearance was to her and her clothing and hair style confirmed this had been taken account of by staff. The other case-tracked resident commented it was, “Nice and quiet here”. Staff were observed, at this inspection, treating residents with respect. There was a positive atmosphere within the Home. Residents’ wishes concerning arrangements after death were, in some cases, now being recorded. There was the name of a preferred undertaker on one case-tracked resident’s Residents Information Sheet but no recorded preference relating to burial or cremation. Letters sent out to all relatives, following this requirement at the last inspection, were seen. The Acting Manager said that the subsequent information received from relatives was being transferred to files. Other aspects of standard 11 were not assessed on this occasion. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 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 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Routines of daily living were flexible and residents were being given opportunities for stimulation. Residents were able to maintain contact with relatives and exercised choice and control over their lives. They were receiving a wholesome and appealing diet. EVIDENCE: A member of care staff said that residents were able to choose when to get up and most chose to rise after 7am. They were also able to choose where to sit and what to eat, she added. A record of staff-led weekly activities was displayed in the main foyer. Additionally, nail care was being provided fortnightly by a visiting chiropodist and hairdressing, also fortnightly, by one member of the Home’s care staff. A nurse was providing ‘music and movement’. One member of care staff said that, “we have time to offer one to one with residents”. Entertainers were visiting the Home and there were details of an annual boat trip displayed. Periodic trips to local garden centres and pubs took place, the Acting Manager stated. A gazebo was erected in the garden when weather permitted. Both case-tracked residents said they enjoyed the hair dressing experience. One said she was not interested in the organised activities as she didn’t like mixing with people. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 13 The Home’s signing-in book provided evidence of plenty of visitors each day. One relative explained that she visits her mother four times a week and another said she spends two hours every day with her mother, as well as there being visits from other family members. The Acting Manager explained that one resident had very little contact from her family and received a befriending service organised by the local branch of Age Concern. She added that local children’s groups visit at Christmas time. Age Concern also organised advocates for this same resident and another resident. These advocates were involved in the formal care plan review meetings for these two privately funded residents. A document entitled ‘Documentation Access: Service Users and Staff’ was examined. This was satisfactory except that no mention was made of access to ‘third-party correspondence’. There was evidence of residents’ own personal items of furniture in bedrooms. The Home’s four-week rolling menu included two choices of lunch each day and indicated that residents were provided with a varied diet. Some items on the menu, such as curry and liver, were not offered at any mealtime. There was no record being made of what residents eat, if other than the main choice. A chalk-board in the dining room was displaying the lunch menu on the second day of this inspection. It showed a choice of three meals, including two varieties of fish. The food looked appetising and dining tables were laid with cloths and set with condiments and drinks. Adequate quantities of food were being served. Two staff were seen helping residents to eat. A number of residents expressed positive comments about the quality of food provided and one said, “Can’t fault the food here”. Relatives spoken to confirmed these views. Dietary sheets were seen on the two case-tracked residents’ files, which included their likes and dislikes. Food levels in the kitchen were satisfactory and there was evidence of homemade cakes being provided. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 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 Quality in this outcome area is ‘Poor’. This judgement has been made using available evidence including a visit to this service. Residents felt confident that their complaints will be listened to. However, records of complaints, including adult protection matters, were not being fully maintained. Residents were not being protected from abuse. EVIDENCE: The Home had a satisfactory complaints procedure displayed in the entrance hall. Three complaints had been recorded over the last 12 months. The first two had been investigated by Ashmere Care Group but the outcome of the investigations had not been reported back to the Home’s Acting Manager or recorded on the Home’s complaints records. A letter from the Acting Manager to the complainant, in respect of the third complaint, was seen to be a satisfactory response, though not all matters had been addressed – see Standard 18 below. One case-tracked resident stated that when she had some concerns over her medication the matter was sorted to her satisfaction and she felt able to share her feelings with staff. An element of the last complaint, received in April 2006, should have been reported to the local office of the Social Services Department under the local Protection Of Vulnerable Adults (POVA) procedures. This did not occur. The Acting Manager confirmed that the Home’s Adult Protection procedures had still not been reviewed (an outstanding requirement from previous inspections). The Acting Manager and Acting Deputy Manager had attended the local Social Services training on Adult Protection and Ashmere Care Group Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 15 had provided in-house adult protection training to most staff, the Acting Manager reported. She was unable to find the Derbyshire County Council’s policies and procedures on Adult Protection though there was a copy of the DCC Report Form pad. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 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): 19,24 & 26 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were living in a generally safe and well-maintained environment: just one Health & Safety matter required attention. Their bedrooms were comfortable and personalised. The Home was clean and hygienic. EVIDENCE: The grounds around the Home were attractive and well maintained. A number of environmental defects highlighted on previous reports had been addressed. The corridor carpet in front of room 17 was split and therefore a potential trip hazard. The Acting Manager said the carpet was due for replacement. The main entrance door can only be opened from the inside by a turn-knob. While this makes it secure from intruders there was the possibility, the Acting Manager said, that a mentally confused resident may be able to operate the turn-knob and be at risk having left the building. Toilet icons had been placed on toilet doors near to one ground floor bedroom in which a resident, who becomes disoriented, is accommodated, the Acting Manager pointed out. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 17 There was an adequate supply of hot water to the residents’ wash hand basins where there had been problems at the last inspection. Other aspects of standard 21 were not assessed on this occasion. The bedrooms that were inspected were well personalised and had a range of attractive soft furnishings. The Acting Manager stated that some bedrooms had had replacement furniture. She also stated that, of the current 18 residents with nursing needs, 9 already had adjustable beds and a further two a month were planned. One of the case-tracked residents had an old, unattractive metal hospital bed and the Acting Manager was proposing to allocate one of the new beds to her. There was recorded evidence, on care plans, that residents had been informed that they are entitled to the provision of comfortable seating for two people and a table to sit at. The Home was clean and with no unpleasant odours. The Acting Manager stated that storage racks in the two sluice rooms had been ordered to enable the correct storage of urinals/commode pans. She added that all residents were due to be re-assessed for continence materials. The ‘Safe Disposal of Clinical Waste’ policy did not state how soiled items should be transported to sluice rooms. It referred to “when the clinical waste bag is full” even though signs in the sluice rooms tell staff to fill the bags to ¾ full. Care plans and risk assessments included explicit mention of aiming to reduce the risk of infection by keeping bedrooms clean. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents’ needs were being met by a staff group of adequate numbers. They were in safe hands in that more than half of the care staff group were qualified. Residents were being supported by the Home’s recruitment procedures but staff could not fully meet all residents’ needs due to a training shortfall. EVIDENCE: Staffing levels were assessed by discussion with the Acting Manager and examination of the rota sheet for week commencing 15 May 2006 – these were found to be satisfactory. The General Manager spoke of the flexibility to move staff from the adjacent care home if necessary. It was clear from the rota who the person-in-charge was. Seven of the thirteen care staff had achieved a National Vocational Qualification (NVQ) in Care at least to level 2 – three had a level 3 NVQ. The personal files of two recently appointed staff were examined at the last inspection. All records required by Schedule 2 of the Regulations, prior to amendment in July 2004, had been in place except for recent photographs. These were now in place. No staff had been appointed since the last inspection. The ‘Staff Personal File Checklists’ were being reviewed to take account of the revised Regulations, the General Manager said. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 19 Employee Induction Packs were seen to follow TOPPS standards. These were being introduced retrospectively to all care staff, the Acting Manager stated. The nurse with responsibility for overseeing staff training provided a record of induction packs handed to care staff between March and May 2006 – none of these had yet been returned. There was a good range of ongoing training provided to staff. Considerable improvements had taken place though there was still room for improvement. The nurse said that approximately half of the staff group had undertaken Basic Food Hygiene and First Aid training recently and most had undertaken Moving & Handling training. However, there was evidence that night staff were not being provided with Fire training twice a year – the last main session was held in September 2005. It was not easy, from existing records, to achieve an overview of the staff training undertaken. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from the positive atmosphere in the Home and its quality assurance systems. The Health and Safety of residents was being promoted except for one matter relating to the smoking room. EVIDENCE: There has been no registered manager in post since 15 June 2005 when the last manager handed in her notice. However, the Acting Manager confirmed that she was about to forward to the Commission a completed application to be the registered manager at The Firs. She stated that she had achieved a National Vocational Qualification in ‘Care’ at level 4. It was clear from this and the previous inspection that there had been a significant improvement in the atmosphere in this Home over the past 12 Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 21 months. One member of staff commented that there was a, “happy atmosphere”, and she found her job, “fulfilling and rewarding”. Both casetracked residents commented positively about staff – one said, “all staff are friendly”. The Monthly Regulation 26 Quality Control Report for May 2006 was examined. This was comprehensive and included completed questionnaires from two staff, one resident and one relative. The agenda and minutes of past residents/relatives meetings were also examined. These took place twice a year, on average, and residents and relatives spoken to confirmed they were invited. No residents’ personal monies were being held by the Home. The Acting Manage stated that the Home’s fees include an element for hairdressing and outings. Accident records were examined. These included follow-up notes, which is good practice. One resident had fallen out of bed four times during May 2006 and the pressure mat by the bed had alerted staff. This resident had suffered no injuries so far. The GP had refused to visit when guidance was sought from the Acting Manager. The kitchen larder was found to be clean and tidy and food hygiene practices were good. There was a split seal on the door of one refrigerator. One resident was making sole use of the Home’s ‘smoking room’. The Acting Manager said she had poor eyesight and her skirt was full of ash with at least one cigarette burn hole in it. It was not clear whether there was a heat detector in this room. There was a solid door to this room with no glass panel. The main cleaning materials store was tidy with User Application Charts, and first aid measures, in place. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 2 17 X 18 1 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Timescale for action Medication Administration Record 01/07/06 (MAR) sheets must include a recorded signature and date when the medication is received. A record must be maintained 01/07/06 within the Home of the outcome of any investigation into complaints made about the Home. The home must have a policy on 01/08/06 Adult Protection in line with the DOH guidance, No secrets. The Social Services have such a policy, which should be obtained. (Previous timescale was 1/6/04) All allegations of abuse must be 01/07/06 followed up promptly and follow the local POVA procedures. The action taken must be recorded and this record must be maintained within the Home for inspection at any time. The corridor carpet in front of 01/07/06 room 17 must be repaired to prevent trips. Staff must be provided with 01/09/06 further mandatory training, especially in Basic Food Hygiene, First Aid and Fire. Fire training DS0000002116.V294446.R01.S.doc Version 5.1 Page 24 Requirement 2. OP16 17(2) Sch 4.11 3. OP18 12(1)(a) 4. OP18 12(1)(a) 17(1)(3) Sch 3.3(j) 5. 6. OP19 OP30 13(4)(a) 18 Firs, The 7. OP38 13(4)(a) must be provided twice a year for night staff. The safety of the resident making sole use of the Home’s ‘smoking room’ must be addressed by means of a heat detector in this room and a glass observation panel in the door. 01/08/06 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 OP1 Good Practice Recommendations The Home’s Statement of Purpose should include all of the matters referred to in Standard 1.1 of Edition 3 of the National Minimum Standards. (This was a previous requirement) The Home’s contract with residents should mention that residents are able to move in on a trial basis. (This recommendation was not assessed) Equipment that carries a degree of restraint such as lap belts and alarm mats must only be used following multidisciplinary assessment and agreement. This must be subject to review. (This was a previous requirement) Residents using baths should have easy access to the Home’s emergency call system. (This was a previous requirement) The Home’s written policy on residents’ and staff members’ access to personal records should make mention of access to ‘third-party correspondence’. The Home’s menu should accurately reflect the meals provided to residents. Records of food provided for residents should be in sufficient detail to determine that each resident’s diet is satisfactory. The Home’s Acting Manager should be informed of the outcome of any investigation into complaints made about the Home. Consideration should be given to an alternative form of security for the main entrance door. A system for cleaning wheelchairs should be DS0000002116.V294446.R01.S.doc Version 5.1 Page 25 2. 3. OP5 OP8 4. 5. 6. 7. 8. 9. 10. Firs, The OP10 OP14 OP15 OP15 OP16 OP19 OP22 11. 12. OP24 OP26 13. 14. 15. OP30 OP38 OP38 commenced.(This recommendation was not assessed) Further adjustable beds should be provided for residents receiving nursing care. The ‘Safe Disposal of Clinical Waste’ policy should state how soiled items should be transported to sluice rooms. It should also refer to filling the clinical waste bags to no more than ¾ full. An ‘At a glance’ record of staff training undertaken should be produced. The Acting Manager should pursue other means of obtaining professional advice concerning the resident who has been falling out of bed. The split seal on the door of one refrigerator should be attended to. Firs, The DS0000002116.V294446.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Firs, The DS0000002116.V294446.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. 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