Inspection on 06/04/06 for The Firs

This inspection was carried out on 6th April 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 09/02/09

The Firs 05/09/08

The Firs 18/03/08

The Firs 14/03/07

The Firs 19/10/05

The Firs 27/07/05

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 Mrs Jayne White Key Unannounced Inspection 6th April 2006 08:45 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 Firs DS0000018252.V288279.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 Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Firs Address 186c Dodworth Road Barnsley South Yorkshire S70 6PD 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) 01226 249623 01226 249623 None Mr Azar Younis Mrs Susan Hunter Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 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 its sister home, Dorothy House. The Firs has a lawned area and a small car parking area to the front. The garden area was accessible to residents. On 6 April 2006 the fees for the home ranged from £302.50 to £320.00. The home did not have a service user guide that included information about the service for current and prospective residents. The latest CSCI report was available in the office for current and prospective residents. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit carried out between the hours of 8:45 and 16:15. The home was asked for information to assist with the site visit on 27 March 2006. This was requested in writing on the 28 March 2006. This information had still not been received by 3 May 2006, therefore, the opportunity to undertake a wider sample of stakeholder’s opinions of the service was unable to be carried out. Opportunity on the visit was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, relatives, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to three members of 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 three relatives. The inspector wishes to thank the residents and staff for their time and co-operation throughout the inspection process. In addition the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. What the service does well: Comments made by residents who lived at the home identified that they felt well cared for and a comfortable standard of accommodation was provided. Comments made by residents about their lifestyle at the home included “carers’ seem nice – that they really care – one stands out as kind and caring – does that little bit more”, “can’t do the things I used to do like knitting but nothing that I would like to do that I can’t – I like to be amongst people”, “I spend time reading bible and the church visit regularly”, “meals are quite good – likes most things and there are alternatives”, “it’s smashing here”, “all the staff are lovely”. Relatives commented that generally their relatives were happy and content at the home, they were kept informed of their relatives welfare, their relatives were brighter and stronger in spirit since going into the home and because they had their hair done regularly looked better cared for. Residents moving into the home had their needs assessed to ensure the home was able to care for them. Nobody that was spoken with had any complaints and the complaints procedure was displayed in the entrance to the home to be used if necessary and clearly identified the procedure to be followed should anyone wish to make a complaint. Agreed staffing levels were met and discussions with residents confirmed there were sufficient staff to meet their needs. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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 DS0000018252.V288279.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 The Firs DS0000018252.V288279.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): The outcomes for standards two and three were inspected. Standard 6 is not applicable. That each resident has a written contract/statement of terms and conditions with the home was not met. This means some residents were not clear of the cost of their stay, how it is to be paid for and the terms and conditions with which they live at the home and the notice they have to give if they wish to leave. All residents moving into the home had, had his/her needs assessed. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager said no further work had been done on the statement of purpose and service user guide, therefore it could not be inspected any further and the requirement carried forward. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 9 The contracts for three residents were requested. Two of the three contracts were in place and contained the majority of the information required. The assessment of need for three residents was requested. An assessment was in place for all three residents. The content of the detail in the assessments ranged from basic/broad detail to specific and comprehensive detail. The Firs DS0000018252.V288279.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): The outcomes for standards 7, 8, 9 & 10 were inspected. All resident’s health, personal and social care needs were set out in an individual plan of care, but omissions and lack of detail were evident. Resident’s health care needs were not fully met, as there were occasions when medication prescribed to meet those health care needs were not administered and this demonstrated residents were not protected by the home’s practices for dealing with medicines. Residents rights to privacy was maintained, however, the discussions and banter between staff did not always show respect for the residents’ as individuals. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 11 EVIDENCE: Residents spoken with spoke positively about their personal care needs being met. Three individual care plans were inspected on a sample basis. They were not always dated and were not signed by the person drawing up the plan. They did not demonstrate they had been reviewed for some time. The plan contained relevant information on the care required to meet the resident’s health and personal care needs but was brief and did not describe in detail the action to be taken by care staff to meet those needs. For example, the frequency of baths or showers and the recording in the care plan when these had taken place. This was because there were a number of ways of recording this information. Although risk of falls were identified in the plan this had not been assessed within a risk management framework and therefore action to take to reduce the risks were not specific and the plan did not contain any information regarding the management of the resident’s finances. Professional intervention was sought where necessary to meet residents’ health care needs although one resident had been without some medication for five days, which may have affected their health and well being. The home was told to ensure medication for the resident was received immediately. The recording, administration and storage of medication were inspected on a sample basis. Medication was appropriately stored. The member of staff on duty administering medication had, had medication training and their induction to the medication administration at the home had been shadowing another member of staff, no one had assessed their capability to administer medication. Administration of medication was observed. The staff member had taken appropriate hygiene measures as was possible but the home had insufficient medication pots for medication to be dispensed in to. The home was asked to order some more. Medication was signed for prior to being given to residents, but residents with “as required” medication were asked about whether they required the medication. The member of staff sat and waited until the resident had taken their medication. Inspection of the medication administration record and medication identified medication to be discarded 28 days after opening had no record of when it had been opened, the quantity of medication received by the home was not always recorded and there were gaps in medication recording where it couldn’t be confirmed whether residents had received their medication or not. Staff were able to describe the measures they took to maintain the privacy and dignity of residents’. There were times when the discussions and banter between staff excluded residents but was about them which was unacceptable and does not promote care and respect for the resident. One resident put this in to words - “Sometimes carers’ joke with me. It might be a joke to them but it’s not to me”. A record within a daily record identified a resident had been told to “get back to bed”. This was discussed with staff who said that wouldn’t happen but whether it did or did not that type of command is unacceptable and does not promote care and respect for the resident. The Firs DS0000018252.V288279.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): The outcomes for standards 12, 13, 14 & 15 were inspected. Discussions with residents and relatives described how on the whole the lifestyle they experienced within the home met their expectations and preferences and satisfied their social, religious and recreational interests and needs, but this could be improved. Residents maintained contact with family and friends and members of the local community as they wished. Residents on the whole were assisted to exercise choice and control over their lives, but a person centred approach would minimalise the institutionalised approach to bathing. Residents received an appealing diet in a pleasant dining area at traditional meal times, although a more positive choice for those on special diets would enhance their meal. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 13 EVIDENCE: Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed, however, in regard to bathing there were identified days for each resident. Discussion with a member of staff said if they refused they could have one on another day if they wanted but this was not demonstrated in the recording and meant one resident had not had a bath for two weeks. Some of the comments made by residents about their lifestyle at the home included “can’t do the things I used to do like knitting, but nothing that I would like to do that I can’t – I like to be amongst people”, “religion important to me – I spend time reading bible and the church visit regularly”, “I get a bit fed up on a night – they don’t all like playing dominoes. I like doing crosswords and puzzles but not watching TV”, “I’m happy here”. It was positive that one carer encouraged a resident to assist with the activity of laying the tables for lunch, providing stimulation for the resident, maintaining their daily living skills and making the resident feel valued. The majority of residents were observed to spend time in the lounges looking at each other with occasional interaction between them and/or the staff, whilst others had chosen to spend their time in the privacy of their bedroom. One relative said this was what they found when they visited and that more stimulation could be provided. Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. Personal items and furniture were brought into the home by residents to personalise their rooms. The dining room was very welcoming, being bright and clean. The menu for the day was displayed outside the kitchen. Comments from residents about the meals included “meals are quite good – I like most things and there are alternatives”. Lunch was well presented and consisted of gammon, potatoe mash, green beans, leeks and cauliflower. The alternative was fishcake with the same vegetables. This was discussed with the manager. Desert provided a choice of ginger pudding and custard, custard tart, yoghurt and fruit. All were freshly prepared and served by the cook on duty who was aware of special diets and likes and dislikes. When the meals were served they were unhurried and residents’ were given sufficient time to eat. The Firs DS0000018252.V288279.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): The outcomes for standards 16 and 18 were inspected. Residents and relatives were confident their complaints would be listened to and acted upon. Residents were not sufficiently protected from abuse as a staff member did not know the correct reporting procedure should an allegation of abuse be made. This may result in inappropriate action being taken should an allegation of abuse be made. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The complaints procedure ensured that residents and/or their advocates were aware of how to make a complaint and who would deal with them. Residents said they were satisfied with the care provided and had no complaints. One resident commented “I have no complaints – if I needed to complain I would do and I think they would listen”. No complaints had been made since the last inspection. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 15 The home had Barnsley Metropolitan Borough Council’s multi agency procedures for adult protection in place. On recruitment, staff were appropriately checked against the ‘Protection of Vulnerable Adults Register’. Some staff had, had training in the protection of vulnerable adults. One member of staff identified that if an allegation of abuse should be made they would make sure the resident was safe and remove the alleged abuser but did not know how to report the abuse should the manager not be available or involved themselves. The Firs DS0000018252.V288279.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): The outcomes for standards 19 & 26 were inspected. The living environment was in the main well maintained, clean and safe. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The building was generally clean and there were no unpleasant odours. Residents were pleased with their living environment with comments including “cleaners good – room cleaned every day and bed stripped regularly” and “I’ve got a lovely room that’s kept nice and clean”. One corridor was in the process of being redecorated and the lighting had been improved to make it lighter for residents on the corridor. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 17 Laundry facilities were sited away from food preparation and storage areas. Hand washing facilities were provided. A member of staff working in the laundry confirmed they had obtained their NVQ in Good Housekeeping, had, had training in control of substances hazardous to health and health and safety. Staff were able to describe the measures they took to control the spread of infection. The Firs DS0000018252.V288279.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): The outcomes for standards 27, 28, 29 & 30 were inspected. Resident’s needs were met by the numbers and skill mix of staff. Residents were not always in safe hands, as all medication prescribed was not administered and they were assisted to move in ways that did not promote their safety. Residents were protected by the home’s recruitment policy and practices. Staff were trained to do their jobs but did not always put this training into practice in the work place, for example, the administration of medication and assistance residents were given to move. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The staff rota for the week of the inspection demonstrated that minimum staffing levels were met. On the morning of the inspection the manager, a senior care, two care staff; a domestic, laundry assistant, cook and kitchen domestic were on duty. Discussions with residents and observation of care practice between staff and residents confirmed there was sufficient staff to meet their needs. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 19 Approximately eighty one per cent of staff held NVQ Level 2 in Care. Of those eighty one per cent, thirty eight per cent held NVQ Level 3 in Care. Staff that were spoken with demonstrated they had undertaken a range of training including NVQs, medication, care planning, catheterisation, fire training, managing challenging behaviour and dementia, nutrition, emergency aid, people moving people and protection of vulnerable adults. It was apparent, however, during the inspection that the training was not consistently effective in the workplace, in particular, the administration of medication and the moving and handling of residents. In addition newly appointed members of staff were not given appropriate induction, including policies and procedures to be followed and were being left in charge of the home. Residents stated that they were satisfied with the level of care they received and that staff knew how to care for them. Two staff files were inspected, one on a sample basis. A thorough recruitment procedure had been followed demonstrating no gaps in employment, receipt of two references, health declaration of physical and mental fitness to do the job and a CRB check before the staff member had commenced employment. Certificates to demonstrate qualifications and training of staff were also in place. The Firs DS0000018252.V288279.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): The outcomes for standards 31, 33, 34, 35, 36, 37 & 38 were The manager did not demonstrate that she fulfilled all her responsibilities, including a lack of an effective quality assurance and monitoring system based on seeking the views of residents and other stakeholders, observing care practice and putting measures in place to make improvements. Residents’ financial interests were safeguarded. Staff were not appropriately supervised. The home’s record keeping and policies and procedures of the home did not wholly safeguard residents’ best interests. The health, safety and welfare of residents were not wholly promoted and protected. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 21 EVIDENCE: Although the manager said the owner was now coming to the home two to three times a week the last regulation 26 visit record was December 2006. The information it contained was poor. When asked if the owner had completed this, the manager initially said “yes” and then said “I’m not lying – no, I’ve completed the form”. When asked why the manager stated “the owner had asked her to”. She confirmed the owner had not dictated the information to her, thus the information was of no value. This did not demonstrate a proactive involvement to improve the quality of the service provided and brings into question the owner and manager’s integrity. It must be noted, however, that residents’ that were spoken with during the day expressed satisfaction with the service. An up to date insurance certificate was in place. The record of monies held on behalf of a resident was maintained with the balance and monies correlating. The description of where the money came ‘in’ and ‘out’ from was adequate and the exchange of finances were verified by two signatories. Receipting mechanisms were in place for monies that were spent. There were safe facilities to store the monies. Discussions with staff identified they were not receiving appropriate supervision. One method of supervision was by notices being left on bathroom doors to remind staff of their responsibilities. This is not the most appropriate method and detracts from maintaining a homely environment for the residents. 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. When the building was inspected no fire exits were blocked and the fire extinguishers seen had been serviced. The emergency lighting, fire extinguisher and the alarm had all been serviced, however, although the manager said weekly checks of the emergency lighting and monthly checks of the fire extinguishers were carried out, there was no documentation to demonstrate this. A sample of staff fire training and drills were inspected and found to be satisfactory. Documentation had not been provided to the CSCI to confirm servicing of the gas cooker, fixed wiring and central heating system, together with confirmation that appropriate repairs/replacements had been completed. An immediate requirement was made. Confirmation that the fixed wiring was satisfactory was received subsequent to the inspection, the others remain outstanding. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 22 There were appropriate measures in place to ensure the security of the premises and prevent intruders. Window restraints had been fitted to windows to prevent falls. There was evidence portable appliance testing had taken place. The moving and handling of some residents was not safe and placed residents at risk of injury, for example, moving residents’ without footplates on wheelchairs and placing arms under residents shoulders when moving them from chairs. Notifiable incidents were not being reported to the CSCI and therefore were not complying with regulations to keep the CSCI informed of incidents/events that had happened at the home. Resident’s accidents at the home were being recorded. Bathrooms continued to be used as storage areas, which did not promote the use of the bathrooms by residents. The water temperature record identified water temperatures were last checked on 8 November 2005, which is not adequate to promote the health and safety of residents. The Firs DS0000018252.V288279.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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 3 3 1 2 1 The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4, 5 & 17 Requirement A copy of the statement of purpose and service user guide, that includes all the requirements of the regulations must be submitted to the CSCI. Required since 1 April 2002. All residents must have a contract/terms and conditions with the home. The care plan must reflect the health, personal and social care needs to be provided for the resident. The plan must be reviewed at least monthly and reflect any change in need if necessary. Medication must be obtained for the identified resident. Medicine pots must be ordered. The quantity of medication received into the home must be recorded and/or verified. There must be no gaps in the recording of medication. There must be a system in place that identifies the date when medication must be discarded. Staff must speak about/to DS0000018252.V288279.R01.S.doc Timescale for action 31/07/06 2. 3. OP2 OP7 5 & 17 15, 16 & 17 31/07/06 31/07/06 4. 5. 6. 7. 8. 9. The Firs OP9 OP8 OP28 OP9 OP9 OP9 OP9 OP10 12 & 13 12 & 13 12 & 13 12 & 13 12 & 13 12 06/04/06 07/04/06 07/04/06 07/04/06 07/04/06 31/05/06 Page 25 Version 5.1 10. OP18 OP31 OP33 13 & 18 11. OP29 18 12. OP30 18 13. OP33 OP31 24 14. 15. 16. OP33 OP36 OP31 OP37 26 18 17 17. OP38 13 & 23 18. OP38 OP33 OP31 OP7 13 19. OP38 37 residents with respect and take account of their feelings. The manager must ensure that staff left in charge of the home are aware of the policies and procedures of the home including the action to take should an allegation of abuse be made. The Code of Conduct and Practice set by the GSCC must be implemented. Required since 1 April 2002. New members of staff must receive structured induction training appropriate to the role they perform. A formal, verifiable quality assurance method must be implemented to enable residents to contribute to the way the service is delivered and a copy submitted to the CSCI. Required since 1 April 2002. A report as required by the regulation must be undertaken and submitted to the CSCI. Staff must be appropriately supervised. All records required by the regulations must be in place, up to date and accurate. (These have been identified throughout the report). Bathrooms must not be used as storage areas. Previous timescale of 31/12/05 not met. Staff must not move residents by placing their arms under their shoulders. Footplates must be used on wheelchairs unless the decision not to is part of a documented risk assessment and identified in the individual plan of care. Notification of death, illness and other events as required by the regulation must be submitted to DS0000018252.V288279.R01.S.doc 31/05/06 31/05/06 31/05/06 31/07/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 The Firs Version 5.1 Page 26 20. OP38 23 21. OP38 13 the CSCI. The weekly testing of emergency lighting and monthly testing of fire extinguishers must be documented. Regular checks of water temperatures must be carried out and documented. 31/05/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP14 OP36 OP31 Good Practice Recommendations Residents should be consulted about their social interests and facilitate this through a programme of activities on behalf of the care home. A more person centred approach to bathing should be implemented and identified and recorded in the individual plan of care. Notices reminding staff of their responsibilities should not be placed on toilet/bathroom doors. The Firs DS0000018252.V288279.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sheffield Area Office 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 DS0000018252.V288279.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!