Inspection on 27/07/05 for The Firs

This inspection was carried out on 27th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 09/02/09

The Firs 05/09/08

The Firs 18/03/08

The Firs 14/03/07

The Firs 06/04/06

The Firs 19/10/05

The Firs 21/01/05

The Firs 02/06/04

The Firs 09/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Firs 186c Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector Jayne White Announced 27 July 2005 08:45am 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 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 Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Firs Address 186c Dodworth Road Barnsley S70 6PD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01226 249623 01226 249623 None Mr Azar Younis Mrs Susan Hunter PC Care Home Only 33 Category(ies) of OP Old age - 33 registration, with number of places The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st January 2005 Brief Description of the Service: The Firs is a care home providing personal care and accommodation for 33 older people. The homes registered owner is Mr Azar Younis. The Firs is situated approximately one mile from Barnsley town centre in one direction and the M1 motorway in the other direction. A main bus route passes the bottom of the drive. The home is all on one level and has 25 single and four double bedrooms. The home is on the same site as Dorothy House, although both are registered separately. A variation has been submitted to register Dorothy House and The Firs as one site but registration to do this has not yet been approved. The Firs has a lawned area and a small car parking area to the front. The garden area is accessible to residents. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The CSCI, proprietor and manager met on 18 May 2005 to discuss improvement plans for outstanding regulatory requirements. As a result this inspection was an announced inspection to facilitate both the manager and proprietor being available and the date was agreed with them on 26 May 2005, however, due to other commitments the proprietor was only available for one and a half hours during this inspection. The inspection took place over nine hours from 8:45 to 17:45. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, their advocates, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to four of the staff on duty about their knowledge, skills and experiences of working at the home, four residents about their views on aspects of living at the home and two advocates on their views of the service provided. Subsequent to the inspection a letter was sent to the proprietor to ask for documentation to demonstrate some previous requirements had been met. What the service does well: What has improved since the last inspection? There was evidence now that residents moving into the home had, had their needs assessed through care management arrangements and been assured that these would be met through the provision of a contract/statement of terms and conditions with the home, although it is recommended more detail is included in the contract/terms and conditions. The manager and staff had undertaken training in adult protection. This had resulted in staff having a good understanding of the procedures to be followed should they suspect any abuse at the home. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 6 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 Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 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 standard(s) 2, 3 & 4. Standard 6 is not applicable to this home. Residents had a contract/statement of terms and conditions with the home although more detail is recommended. Residents moving into the home had, had their needs assessed and been assured that these would be met. EVIDENCE: Documents were provided to the inspector but it was not clear which was the statement of purpose and service user guide and were therefore not checked any further. One resident’s file was inspected in regard to a written contract/statement of terms and conditions and that their needs had been assessed prior to admission. Both were in place. The contract did not include some of the detail recommended in the standard. The assessment had been received from the placing authority. This confirmed the home was an appropriate placement to meet their needs and the home had confirmed they could meet their needs by providing a contract. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Residents health, personal and social care needs were not adequately set out in the individual plan of care although there was evidence that health professionals were involved to meet health care needs. Residents were still not wholly protected by the homes policies and procedures for dealing with medicines although there had been improvements in some areas. Residents were satisfied with the care they received and no adverse comments were made in regard to staff maintaining their privacy and dignity, however, in the inspector’s opinion the dignity of residents was not wholly maintained as there were residents who were wearing clothes that were dirty/stained and held food debris and incontinence sheets were seen to be used inappropriately. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 10 EVIDENCE: Residents spoken with spoke positively about their personal care needs being met. Individual care plans were in place, however, they did not contain up to date and relevant information including all the information required by the regulations and standards. Examples include pressure area care, dietary requirements and continence needs not being identified on the care plan and moving and handling assessment forms and falls risk assessments not consistently completed. There was evidence care plans were reviewed but not at the required frequency or in sufficient detail when residents needs change. In addition a new system had been implemented for the daily reporting against the care plan. Discussions with staff identified prior training had not been given and they were not clear what to record on which sheet. This was confirmed on inspection of the record. Also one of the recording systems was of a tick sheet type and this can only work if detail on the care plan is sufficiently detailed and well documented, which it was not. There was evidence that residents and/or their advocates were now involved in their care plans. A representative from the home and the resident and/or their advocate did still not verify records of personal possessions brought into the home by residents. Observations by the inspector, such as two residents wearing clothes that were dirty/stained and held food debris did not demonstrate that the personal care needs of all residents were satisfactorily met. Two residents were noted to be wearing stockings that contained large ladders and holes. Discussions with staff, observation of staff administering medication and inspection of MAR sheets were made. The handling of medication had improved and medicines were now being recorded for after being administered to the resident. The storage of medication requiring refrigeration had also improved. Not all staff had received up to date training. There continued to be gaps in the recording of medication and there was instruction for the administration of medication that was found to be inadequate and instructions that had not been followed. Staff were able to describe the measures they took to maintain the privacy and dignity of residents. It was observed however that one resident where assistance with drinking was required that an incontinence sheet had been used to protect clothing. This did not preserve the dignity of the resident. There was a telephone in the home for residents to use. This was in the hallway of the home and therefore would be unable to be used in private. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 11 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 standard(s) 15 Comments made by residents identified they were pleased with the food they were served. EVIDENCE: Over the previous weekend the home had been reorganised to accommodate the dining room in the conservatory due to new dining room furniture making the old dining room look cramped. The conservatory had also been fitted with a new carpet. The majority of residents were pleased with the arrangements although there were reservations including ‘it can be too warm’, ‘it is very bright’ and ‘the area is very vast’. Other comments included ‘there is much more room now’ and ‘I can now use the dining furniture which is much better for me to be able to eat my meals. This pleasant new area and furnishings were spoilt by the tea table being set and tea served with soiled tablecloths on them from lunch time and the areas under the tables still showing signs of crumbs and dirty tissues. Meals were unhurried with residents being given sufficient time to eat. Hot and cold drinks were available and offered between meals. The menu for the day was displayed in the lounge. Meals were discussed with residents and one resident commented ‘they’re much better now we’ve got the new cook’ and staff also commented how the new cook was very involved with the residents and how he accommodated their choices. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 12 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 standard(s) 18 Staff had a good understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: The manager confirmed the home had a copy of the local multi agency policies and procedures in regard to the protection of vulnerable adults. A referral under those procedures identified in the previous inspection report was unresolved but action included both the manager and staff undertaking training in adult protection. Discussions with the manager and two members of staff identified they had, had this training and would report any allegation of abuse appropriately. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 21, 23, 24, 25 & 26 The communal living environment was on the whole well decorated and maintained and residents and their advocates on the whole felt a comfortable standard of accommodation was provided. One bedroom was identified for refurbishment. The home had sufficient number of baths, showers and toilets and specialist equipment was provided where required. Observations, inspection and discussions with staff during the inspection identified there were areas of the home that were not clean, care was not taken with the return and ironing of residents clothing and appropriate procedures were not used to control the spread of infection which also compromised the dignity of residents. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 14 EVIDENCE: Residents spoken with did say that on the whole they were satisfied with the homes living environment. They said that they felt the old dining room that was now being used as a lounge area could do with ‘brightening up’ and said a representative of the owner had agreed. The manager confirmed this and that decoration and new curtains would take place. On the whole the communal areas were well decorated and maintained. The grounds were tidy, attractive and accessible. The home did have a sufficient number of baths, showers and toilets. They were close to bedrooms, lounges and dining areas. Doors were labelled and had privacy locks. There were appropriate aids and adaptations – e.g. raised toilet seats, grab rails, specialist baths. One double room did not meet the minimum size identified in the standards. A variation had been submitted to the CSCI and this is to be addressed as part of that process. Discussions with residents and/or their advocates confirmed they were happy with their rooms, however, one room inspected displayed evidence of cracking wall paper, decoration looked ‘tired and old’, furnishings the same in addition to varnishing being worn and marked. Rooms were centrally heated to ensure residents were warm enough. The monitoring of radiator and water temperatures had been kept up to date and records identified they remained at an adequate level. Lighting levels were sufficient to facilitate reading and other activities and there was emergency lighting in the dining room, lounge and corridor areas of the home. The building was free from offensive odours. Laundry facilities were sited away from food preparation and storage areas. Hand washing facilities were provided. The laundry floor was impermeable and the walls washable. There were toilet areas that did not have paper towels provided, soiled laundry and continence wear were seen to be carried to the laundry and the home did not have a sluice. This compromised the control of infection and discussions with some staff confirmed they had, had training in infection control. Parts of the lounge area were very dusty, a bedroom carpet had bits on it and a bin in a bedroom was full which had resulted in disposable gloves that had been used being on the floor. Wheelchairs were dirty. Laundry placed in baskets ready to be returned to residents were not always for the correct person, some had not been ironed and some of the garments were not folded with care. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 & 30 Staff were undertaking training, which enabled them to meet the needs of the residents in the home. EVIDENCE: The manager stated approximately forty seven per cent of staff held NVQ Level 2 and 3 in Care or a Diploma in Direct Care with all staff enrolled on NVQ Level 2 in Care. Discussions with staff confirmed they had, had a range of training including health and safety, moving and handling, fire, first aid, food hygiene and infection control. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 37 & 38 An appropriate quality assurance system was not in place for residents and relatives to express their views on the home and the care they received. Likewise for staff. Staff were not being appropriately supervised. Resident’s rights and best interests could be placed at risk by the homes failure to maintain all records adequately. Some areas relating to health and safety issues required attention, in order to enhance the safety and welfare of both residents and staff. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 17 EVIDENCE: The manager had produced a questionnaire for residents on the quality of the service provided, however, this had not yet been implemented. It was discussed with the manager that the questionnaire wasn’t the only method of quality assurance and areas that were inspected demonstrated measurable methods of quality assurance had not yet been implemented. Discussions with staff identified staff meetings were still not held. This was discussed with the manager and proprietor and the proprietor has stated staff meetings will commence, that he will attend them and they will be minuted. There continued to be a number of previous requirements that had not been met. The proprietor does not respond to requirements in inspection reports to identify how they will be addressed and by when. Since the meeting on 18 May 2005 two regulation 26 visits have been submitted to the CSCI. One for June is still outstanding although Azar Younis said this had been completed. Also at that meeting Azar Younis stated his time spent at the home would increase and some administration duties would be taken from the manager so she could spend more time on the management of care. This hadn’t happened, Mr Younis still citing his other commitments as the problem. He said he expected this to improve at the end of August 2005. It must be noted however that residents and/or their advocates that were spoken with during the day expressed satisfaction with the service. Discussions with staff did not confirm that supervision did take place. A sample of records that the home is required to keep have been commented upon throughout the report and requirements made. Records were securely stored. Staff confirmed a health and safety policy was in place. Discussions with staff identified training was in place for health and safety, moving and handling, first aid, food hygiene and infection control. When the building was checked no fire exits were blocked and the fire extinguishers seen had been serviced. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Window restraints had been fitted to windows in communal areas to prevent falls. One window restraint was broken. A sample of electrical appliances in the home were inspected. They did not display evidence of PAT testing. There was a staff member on shift qualified in first aid. A notifiable incident had been sent to the CSCI since the meeting on 18 May 2005. During the inspection the kitchen door to the outside was left open and a fly screen was not fitted to prevent insects from coming into the kitchen. The door leading into the kitchen from within the home had also been left open. The area was not supervised and was a safety risk to residents. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x 2 2 3 1 STAFFING Standard No Score 27 x 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 1 x x 1 1 2 The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 19 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 1 Regulation 4&5 Requirement A Statement of Purpose/Service User Guide that includes the entire requirements in the regulations must be produced, in a format suitable for the needs of residents. Required since 1 April 2002. Copies must be submitted to CSCI. The most recent report must be included in the service user guide and this must be available for residents and their advocates to read without having to ask for a copy. Required since 31 July 2004. The care plan must set out in sufficient detail the action which needs to be taken by care staff to ensure all aspects of the health, personal and social care needs of the service user are met. The plan must be reviewed at least once a month or sooner, if required, to reflect the changing needs of residents in relation to their health, personal and social care. Timescale for action 30 September 2005 2. 1 5 30 September 2005 3. 7&8 15, 16 & 17 30 September 2005 The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 20 4. 7 15, 16 & 17 5. 6. 7 7 18 17 7. 9 13 8. 9 18 9. 9 13 10. 9 13 The care plan must contain a nutritional risk assessment of the resident and identify the social interests, hobbies, religious and cultural needs of the resident and accommodate this on an individual basis if necessary. Previous timescales of 31 May 2004, 31 October 2004 and 31 March 2005 not met. Staff must receive training on the new system of daily reporting against the care plan. Both the person completing the documentation and the resident and/or their advocate must sign records of residents furniture and personal possessions brought into the home. Previous timescale of 31 March 2005 not met. Arrangements must be made to ensure that staff are aware of the reasons for administering a particular type of medication and of any side effects. Previous timescale of 31 July 2004 not met. The training in medication must include basic knowledge of how medications are used, how to recognise problems in use and a formal assessment of the staff members capability to safely administer medication. Required since 1/4/2002. Administration instructions identified on the MAR sheet must be checked when medication is received into the care home to ensure the information is correct. Previous timescales of 31 August 2004 & 31 March 2005 not met. Medication must be administered in accordance with instructions. 30 September 2005 30 November 2005 30 September 2005 31 March 2005 Not checked on this inspection 30 September 2005 30 September 2005 30 September 2005 Page 21 The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 11. 10 12 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 10 24 26 26 26 26 26 26 26 27 12 16 & 23 23 12 & 23 13 13 13 23 16 & 23 17 Incontinence sheets must not be used to protect clothing when assisting residents with food or drink. Residents clothing must be free from dirt/stains and food debris and of an adequate quality. The identified bedroom must be redecorated and the furnishings refurbished or replaced. A sluicing facility must be provided. Required since 1/4/02. The dining area must be clean with clean table cloths. 30 September 2005 30 September 2005 28 February 2006 31 October 2005 22. 27 17 30 September 2005 Paper towels must be provided in 30 all toilet and bathroom areas. September 2005 Soiled laundry and continence 30 wear must be dealt with in a September more appropriate manner. 2005 All areas of the home and 30 equipment must be kept clean. September 2005 Bins that are full must be 30 emptied. September 2005 Laundry must be ironed, folded 30 with care and returned to the September correct person. 2005 The roster must define clearly all 30 members of staff who work at September the care home, the position that 2005 they work, the number of hours and to what month the roster relates. Required since 1/4/02. A copy of the rota for week commencing 3 October 2005 must be submitted to the CSCI. The duty rota must correlate 30 with persons that are working on September shift. 2005 The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 22 23. 29 18 24. 29 17 25. 29 19 26. 33 21 & 24 27. 34 26 28. 35 25 The Code of Conduct and Practice set by the GSCC must be implemented. Required since 1/4/02. The staff file must demonstrate the position the member of staff holds at the care home, the work to be performed by them and the number of hours they work. Previous timescales of 31 May 2004 & 31 October 2004 not met. The health declaration must include that the person is physically and mentally fit for the purposes of the work that they are to perform at the care home. Previous timescales of 31 May 2004 & 31 October 2004 not met. A copy must be submitted to the CSCI. A formal, verifiable quality assurance method must be implemented to enable staff and residents to contribute to the way the service is delivered. Required since 1/4/02. A copy must be submitted to the CSCI. Confirmation is required that there is a business and financial plan in place and that accounts are kept to ensure there is effective and efficient management of the business and that these are available if required. Required since 1/4/02. Recording systems, including correlating charges with receipts and confirmation of transactions through two signatures must be improved to safeguard service users financial interests. Previous timescale of 31 October 2004 not met. 30 September 2005 31 March 2005 Not checked on this inspection 30 September 2005 30 September 2005 30 September 2005 31 March 2005 Not checked on this inspection The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 23 29. 35 25 30. 36 18 31. 37 17 32. 38 23 33. 38 18 Records must demonstrate payments made to a third party from the service users financial account by the manager is agreed by the service user. Previous timescale of 31 October 2004 not met. A staff supervision policy/procedure must be implemented. Required since 1/4/02. All records required by the regulations must be in place (identified specifically throughout the report). The gas cooker must be serviced and repairs/replacements made where required. Previous timescales of 31 May 2004 and 31 October 2004 not met. A copy of the service agreement must be submitted to the CSCI Laundry and domestic staff must receive training in health and safety and COSHH. Previous timescale of 30 June 2004 not met. 31 March 2005 Not checked on this inspection 30 September 2005 30 September 2005 30 September 2005 34. 38 13 35. 38 13 All electrical equipment brought into the home must have a portable appliance test to confirm it is safe to be used. Previous timescales of 31 May 2004, 31 October 2004 & 31 March 2005 not met. Confirmation these have been completed must be submitted to the CSCI Fixed wiring installations must be 30 serviced. September Previous timescales of 31 May 2005 2004 & 31 October 2004 not met. A copy of the service agreement must be submitted to the CSCI. 31 March 2005 Not checked on this inspection 30 September 2005 The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 24 36. 38 13 37. 38. 38 38 13 13 Servicing must take place of the central heating system. Previous timescales of 31 May 2004 & 31 October 2004 not met. A copy of the service agreement must be submitted to the CSCI. A fly screen must be fitted to the outside kitchen door. The door leading into the kitchen from the lounge must be kept locked when the area is unsupervised. An audit must be made of all window restraints and where they are broken be repaired. 30 September 2005 30 September 2005 30 September 2005 30 September 2005 39. 40. 41. 38 13 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. Refer to Standard 2 29 33 Good Practice Recommendations The contract/terms and conditions should include all the detail recommended by the standard. A Recruitment and Equal Opportunities Policy/Procedure should be implemented at the home. That staff meetings are held. The Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 Firs J51 S18252 The Firs V236469 27.07.05 UI Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!