Inspection on 16/07/07 for The Firs Residential Home

This inspection was carried out on 16th July 2007.

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 Residential Home 02/07/08

The Firs Residential Home 26/07/06

The Firs Residential Home 07/02/06

The Firs Residential Home 22/06/05

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 The Firs Residential Home 9 Stevens Lane Breaston Derby Derbyshire DE72 3BU Lead Inspector Steve Smith Unannounced Inspection 16th July 2007 10:45 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 Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Firs Residential Home Address 9 Stevens Lane Breaston Derby Derbyshire DE72 3BU 01332 872535 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) The Firs Care Home Ltd Yvonne Marie Pelosi Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Yvonne Pelosi must obtain a qualification of NVQ level 4 in Management and Care by May 2007. 26th July 2006 Date of last inspection Brief Description of the Service: The Firs Residential Care Home provides accommodation for 20 Older People. The building was originally a large Victorian family home that has been extended to its current size. The Home is situated in the village of Breaston, located almost midway between Derby and Nottingham. All bedrooms meet the National Minimum Standard for size, as does the communal space. Two stair lifts, and three staircases, provide access to the first floor. The Home has two lounges, and a seating area in the large reception area of the Home. There is a front conservatory that exits into a patio and garden area, which Residents regularly use. There is a call system, which operates in all areas of the Home. Relatives and visitors can call to visit Residents at any time. The Home is run by the two Registered Providers, one of which is also the Manager. During last year the Home has earned the Investors in People Award 2006. The charge made for a room at the Firs ranges from £330.00 to £350.00 a week. The difference in fee relates to the size of room chosen by the potential new Resident, and whether it is a shared room. A copy of the Commission’s inspection report is available from within the Home. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of nearly 7.5 hours. Discussion was held with two Residents, and the records of three Residents were ‘case tracked’. Discussion was also held with the both Registered Providers, one of who was also the Manager and with one member of the care staff. A number of records were examined, and the bedrooms of the all Residents in the Home were examined, and all public areas of the Home were also looked at. The Commission’s pre-inspection questionnaire, sent to the Registered Provider/Manager, was examined. The Commission’s Residents questionnaire had not been returned by any Residents at the time of this inspection. What the service does well: What has improved since the last inspection? Since the last inspection, in July 2006, the Registered Providers have ensured that the statement of purpose was completed. The Medication Administration Record sheets were found to now be maintained in an accurate manner. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 6 The Registered Provider/Manager has obtained her NVQ level 4 qualification in Management and Care. Training has been provided for all necessary staffing in Fire Safety, First Aid and Food Hygiene. 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 summary of this inspection report can be made available in other formats on request. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. The Guide was well completed, although did not provide the opinions of Residents on what life was like in the Home. The Residents Guide did contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. The records of three Residents were examined, during this visit to the Home, and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. However, these documents did not contain information on the rights and obligations of the The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 9 Resident and Registered Providers and who would be liable if there were a breach of contract. When new Residents were admitted to the Home, the Registered Provider/Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Registered Provider/Manager also assessed all Residents sponsored by Social Services Depts, before deciding on their admission to the Home. If the Residents were self-funding from the outset, the Registered Provider/Manager completed her own summary of needs, which were also seen during this visit to the Home. Standard 6 does not apply to this Home. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being met, although some improvements were needed. Medication was administered appropriately to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of three Residents were examined, for the purpose of case tracking. Almost all of the basic information, concerning each Resident, was found to be in the files examined. That was, their name and date of birth, their next of kin, their GP, their Social Services Dept Care Manager, their keyworker in the Home and their date of entry to the Home. However, in two of the Resident’s files no mention was made of the Residents preferred name. The records of the Registered Provider/Manager’s initial assessment of each Resident were found in each file, although all three of these The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 11 provided only very brief information about each potential Resident. Individual Plans of care had also been provided. But again, in two of the Residents’ files, only very limited information was provided. In the third file, a good copy of the plan of care had been completed. Records of the risk assessments were seen for all three Resident, which were found to be satisfactory. The Registered Provider/Manager had not provided information within the files to say what additional needs Residents suffering with dementia might have had. The records should have included details of each Resident’s possible limitations of choice, freedom and decision making. The files showed that records of events affecting each Resident were kept by the Home, and the records showed that these were shared with able Residents. It was also found that the Registered Provider/Manager had not carried out formal reviews of care, for any of the three Residents, at 6 monthly intervals, to which the Resident and their relatives could be invited. However, it was found that the local Social Services Depts undertook formal review of care on an annual basis. All of the files were easy to read and satisfactory entries had been made by the care staff. The Registered Provider/Manager said that the records of each Resident were reviewed at regular intervals by herself, but the records had not been signed to indicate that this had taken place. The files were well organised, with different sections, and a confidential section had been provided. In one of the Residents files a member of staff had asked other staff to ‘Please observe’ the Resident, concerning a particular problem for the Resident. However, no member of staff referred to this issue in any entry following the request being made. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined, and a good system was found to be in use. Discussion was held with Residents about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘Staff are very good and are happy to always do things my way’. Discussion was also held with Staff, and very positive ways were described of assisting Residents within the Home. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, although attention was needed to the activities provided. Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Residents were asked about the activities provided in the Home. Those spoken to said that the Home used to have an Activities Coordinator, but that she had left, and as a result the number of activities had significantly reduced. Residents said that a singer still called at regular intervals, but little else was provided. Staff were asked about this and they confirmed that a singer called twice a month, but that little else was provided. Staff said that the Activities Coordinator left approximately a year ago. Residents said that they decided when they got up and went to bed – ‘I choose the time I go to bed, about 11.00 pm. I also choose the time I get up.’ Another Residents said that ‘I have one bath a week, but you can have more if you want it.’ The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 13 Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I always take them to my bedroom or somewhere else private.’ The staff spoken with also said that relatives could visit at anytime. It was said that Residents could chose where they wanted to see their relatives, in the lounge, or in their bedrooms. Residents were able to say that when staff came to the door of their bedrooms they knocked and always waited for them to say ‘come in’ before doing so. Residents said that the Home provided good meals and that a choice was available at breakfast, dinnertime and teatime meals – ‘A lot of choices are offered at all meals.’ Staff were able to confirm this. Staff also said that drinks and snacks were always provided between meals for Residents, which was witnessed during this visit to the Home, and that mealtimes were never rushed. Staff were also observed going around the Home asking Residents what they wanted from the menu for the next meal. However, the menus were poorly recorded in the kitchen. The record of meals seen showed that often meals for dinner included items on toast, which was not considered to be a suitable dinnertime meal. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints or concerns raised with the Registered Provider/Manager were addressed to meet Residents needs. The Safeguarding Adults policies and procedures provided meant that Residents were well protected. EVIDENCE: Residents spoken with said that if they had a complaint to make or a concern to raise they would tell one of the Registered Providers. One Resident was able to say if a complaint was raised ‘Oh yes, things change, but things are not often wrong in the Home.’ The Commission had received one notice of complaint since the last visit to the Home, in July 2006. This complaint had been passed to the Registered Provider/Manager to investigate. The results of this complaint were examined and a satisfactory result was found. Since that July inspection, the Registered Provider/Manager had recorded a number of concerns raised by Residents, all of which were found to have appropriately investigated and recorded. Good procedures were seen for both written and verbal complaints. The Registered Provider/Manager’s complaints procedure detailed that all complaints would be responded to by the Registered Providers within at least 28 days. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 15 The Registered Provider/Manager had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. She also had a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ available in the Home. The Registered Provider/Manager confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. So far, however, this procedure had not been needed. The policies and practices laid down by the Registered Provider/Manager ensured that all staff understood physical and verbal aggression by Residents. The Registered Provider/Manager also said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom this was discussed. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the Home, which included all of the bedrooms of the Residents. The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with the appropriate items for the Residents. The bedrooms provided satisfactory space and provision for each Resident. The Registered Provider/Manager had provided appropriate furnishings in all locations seen during this visit to the Home. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 17 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was available throughout the Home. Laundry was found to be washed at appropriate temperatures. However, the following two items needed addressing within the Home: Bathrooms and toilets throughout the Home were provided with emergency call lines for use by Residents, but in some of the bathrooms and toilets they were not placed near to were Residents could reach them. This must be addressed by 31 October 2007. Emergency staff call lines provided in many places around the Home were only provided with a red pendulum at the end of the line. The line itself was white, as is the case of light pulls. The line must also be red. This must be addressed by 31 October 2007. In bedroom 8 the hand basin for use by the Resident was found to be a very small size and was thought to be a hand basin for use in a toilet. A full sized hand basin was needed for use in a bedroom. This must be addressed by 31 October 2007. It was found that the Home was not provided with a sluice room of any type. As a result a bathroom was being used for this, and therefore the number of bathrooms available to Residents was not in line with that required by the Regulations. A separate sluice room must be provided. This must be addressed by 31 January 2008. All bedroom doors must be fitted with a lock that could be operated from both the inside and outside of the room by the Resident. Each Resident must be provided with a key to their bedroom. However, risk assessments needed be carried out and recorded in the Resident’s file where it was considered by the Registered Providers that the Resident was not able to hold the key to their bedroom. Care staff and cleaning staff should be provided with masterkeys to allow them access to Residents bedrooms to carry out their tasks in the Home. This issue had been outstanding from the inspection report of June 2005. This must be addressed by 30 November 2007. It was found that many radiators and pipework in Residents bedrooms and toilets had not been provided with covers to safeguard Residents from accidental burns. This issue had also been outstanding from the inspection report of June 2005. This must be addressed by 30 November 2007. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Care staffing was provided to meet the needs of Residents, and appropriate recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. EVIDENCE: A satisfactory level of staffing was found to be provided in the Home to meet the needs of Residents. However, this was maintained for staff on a weekly basis on a wipe-clean board. The paper record was poorly maintained, and needed considerable improvement. At the time of this inspection it was found that more than 50 of care staff held a qualification of at least NVQ level 2 in Care. The recruitment procedure to be followed by the Home was examined and it was found that no new staff had been employed since the last visit made to the Home in July 2006. This very positive position meant that it was not possible to check the recruiting procedure followed, to ensure it met that laid down by Regulation 19 and Schedule 2 of The Care Homes Regulations 2001. The Registered Provider/Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 19 The records of some of this training was seen. All staff also had an individual training and development assessment and profile. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38 The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained at a positive standard. EVIDENCE: The Registered Provider/Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and Care. However, it was found that the second Registered Provider was not ‘inspecting’ the Home at monthly intervals, as required by the Care Homes Regulations 2001. The Registered Provider/Manager was able to say that she had started to address the Quality Assurance information needed in the Home, in that she had plans for the Home’s development, however, these plans were not written down. The results of Residents surveys were presented, and these were found The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 21 to be also published. The views of family and friends of Residents on how successfully the Home was achieving goals for Residents were said to be discussed during reviews of Residents, but these views were not written down nor were they published. The Registered Provider/Manager was able to show that the personal money of Residents, held by the Home, was maintained satisfactorily. Staff were asked about the regularity of supervision in the Home. The staff said that this was not provided. The Registered Provider said that supervision was provided at 6 monthly intervals only, and not once every 2 months as suggested within the National Minimum Standards. The training required by the Regulations was examined. This showed that Moving and Handling training, Fire Safety training, First Aid training and Food Hygiene training had been provided for all necessary staff. Infection Control training was found to be needed by three staff. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. The Registered Provider/Manager had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Registered Provider/Manager was not able to show that she had provided risk assessments on all safe working practices of staff; that is for care staff, catering staff and domestic staff. Nor had she provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices. Finally, the Registered Provider/Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 3 2 2 3 STAFFING Standard No Score 27 2 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 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 OP7 Regulation 15 Requirement Residents care plans must be completed in detail, to enable care staff to provide appropriate care for each Resident. The Registered Provider/Manager must ensure that each Resident, or their representative, has the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records. Activities must be regularly organised for Residents to take part in. A number of Requirements must be addressed in and around the Home, details of which are including in the section headed Environment Standards 19 – 26. Time schedules for this items are also provided in the above section of the report. An up to date, fully completed, DS0000063245.V341101.R01.S.doc Timescale for action 10/09/07 17(1)(a) & Sch. 3 3(q) 2. OP12 16(2)(m) & (n) 12, 13 & 23 30/11/07 3. OP19 to OP26 31/01/08 4. OP27 17(2) & 10/09/07 Page 24 The Firs Residential Home Version 5.2 (3) & Sch 4 No 7 record of staffing provided in the Home must be maintained, in pen, at all times. This record must be kept for at least three years. The second Registered Provider must ensure that he inspects the Home, on an unannounced basis, at least once each month in line with the requirements listed in Regulation 26. (This Standard should have been addressed from the inspection report of 22 June 2005) The Registered Provider/Manager must ensure that the results of all of her quality assurance programme are published, and made available to Residents, relatives and the Commission. (This Standard should have been addressed from the inspection report of 26 July 2006) Supervision must be provided for all care staff. (This Standard should have been addressed from the inspection report of 26 July 2006) Mandatory training must be provided on Infection Control for the three staff identified at during this visit to the Home. 10/09/07 5. OP31 26 6. OP33 24 31/10/07 7. OP36 18(2) 10/09/07 8. OP38 18(1)(c) (i) 30/11/07 The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 OP2 No. 1. 2. Good Practice Recommendations The Residents Guide should contain the views of Residents on what it is like to live in the Home. The Registered Providers should include in the statement of terms and conditions of residency/contract for living in the Home, information on the rights and obligations of the Residents and Registered Providers and who would be liable if there were a breach of contract. (This issue should have been addressed from the inspection report dated 22 June 2005) The basic information provided within each Resident’s file should include the preferred name of the Resident. The initial assessments of a potential Resident, likely to be moving to the Home, should be completed in sufficient detail to justify the admission of the potential Resident. Formal reviews of care should be undertaken at 6 monthly intervals. Those taking part should at least include staff from the Home, the Resident and their relatives, particularly the ‘personal representative’. The review of care should be shown to the Resident (or representative) for signature. One of these reviews, each year, could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the Resident. (This Standard should have been addressed from the inspection report of 26 July 2006) The Registered Provider/Manager should review each Resident’s file on at least a monthly basis. She could indicate that this has been done by signing the record with a red or green pen. When care staff use the Resident’s record of events to ask other staff to carry out tasks, such as ‘Please observe’, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer 3. OP7 The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 26 needed. 4. OP15 A record of meals provided should be that requested by the Residents, which could be the record taken by staff asking the Residents their choices. The choice of meals at dinnertime, midday, should be of appropriate meals. Meals such as items on toast should be provided at teatime, or if the Residents is unwell and personally asks for a meal on toast. 5. OP36 The Registered Provider/Manager should carry out formal supervision of all care staff, at least 6 times a year. (This Standard should have been addressed from the inspection report of 26 July 2006) The Manager should provide risk assessments, for all staff, on all working practice topics in order to ensure that significant findings are recorded and acted upon. The Manager should also provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. (These Standards should have been addressed from the inspection report of 22 June 2005) 6. OP38 The Firs Residential Home DS0000063245.V341101.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 - 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. 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