CARE HOMES FOR OLDER PEOPLE
The Firs Residential Home 9 Stevens Lane Breaston Derbyshire DE72 3BU Lead Inspector
Steve Smith Unannounced 22 June 2005 09:30 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 Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service The Firs Residential Home Address 9 Stevens Lane Breaston Derbyshire DE72 3BU 01332 872535 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) The Firs Care Home Ltd Yvonne Pelosi Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (OP) (20) of places The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Mrs Yvonne Pelosi must obtain a qualification of NVQ level 4 in Management and Care by May 2007. Date of last inspection 28 October 2004 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 Breaton, located almost midway between Derby and Nottingham. All bedrooms meet the National Minimum Standard for size, as does the communal space. A stairlift, and two staircases, provides 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 Service Users regularly use. There is a call system, which operates in all areas of the Home. Relatives and visitors can call to visit Service Users at any time. The Home is run by the two Registered Providers, one of whom is also the Manager. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours. Discussion took place with the Registered Provider/Manager and records were examined. Two Service Users were spoken to and all bedrooms and all public area of the Home were examined. What the service does well: What has improved since the last inspection?
Since the last inspection, in October 2004, the new Registered Providers have taken control of the Home. The new Registered Providers have brought about considerable improvement to the operation of the Home. Service Users files now contain the initial assessments of needs provided by the Care Manager or Registered Provider/Manager of the Home. All Service Users files contain a copy of the contract/statement of terms and conditions of occupancy for each Service User. The files also contain all the information relevant to each Service User. Service Users are given access to the Service Users Guide to the Home. The Guide contains information on how to make contact with the local Social Services Dept and Health Authority. When a review of care takes place Service Users are provided with a copy of the review. The Registered Provider/Manager reviews Service Users files on a monthly basis. Service Users are given information about local Advocacy Services. Medication Administration Record sheets are now provided with definitions when staff enter a ‘F’ in the record and the dispensing of medication has improved.
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 6 The Registered Providers maintain a copy of the meals provided in the Home for at least three years and provide a choice of meals. Breakfast is now provided at a flexible time. Appropriate soft diets are available. Larger meal portions are also provided. Showers and baths are available to Service Users regularly during every week of the year. In addition, Service Users are able to spend time alone in the bathroom if that is their wish and their ability confirms this. An Activities Coordinator, who attends the Home twice a week, now arranges activities and trips. Staff are now aware of which Service Users bedrooms they must knock and await an invitation to go in, and which bedrooms they must knock at, pause and enter. Lockable storage space is provided to every Service User. Toilet rolls are now attached to appropriate wall brackets. A new washing machine has been provided. Lighting of appropriate strength is provided in all bedrooms. Repairs have been made to damaged furniture. Additional covers are provided when plastic covered mattresses are used. The Home now complies with the Water Supply (Water Fittings) Regulations Staff are informed that they cannot benefit from Service Users wills. Two references are obtained when appointing new staff. Staff are now supervised at regular intervals. All staff are provided with training in Moving and Handling, First aid and Basic Food Hygiene. The staffing is now provided above the level suggested by the Residential Forum. What they could do better:
There is much in the Home that the new Registered Providers need to address. The Home’s statement of purpose needs to be completed, as does the contract/terms and conditions of residency. Each Service User’s Plan of Care needs considerable attention to ensure that all issues are addressed. The Medication Administration Record (MAR) sheets need to be completed without gaps in the signature record. Staff must also record the number of medications given when the MAR sheet says for example, give one or two medications. The Registered Provider/Manager needs to ensure that Service Users are asked about their funeral arrangements within a short time of their admission to the Home. The record of complaints kept by the Registered Provider/Manager did not include verbal complaints, which is how most complaints would be made. When the Registered Providers took over the Home, there were a large number of issues that needed to be addressed in the physical environment of the Home. A large number have been done, although there is much that still needs attention.
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 7 At least 50 of care staff needed to obtain an NVQ level 2 qualification in Care, and the Registered Provider/Manager needed to begin her qualification in Management and Care. The Home needs to be ‘inspected’ on an unannounced basis at least monthly. The Registered Providers need to commence a Quality Assurance system. Lastly, the Registered Provider/Manager needs to provide assessments on all work practice topics for staff. 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 Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 & 3. The statement of purpose and Service Users Guide does not provide Service Users with clear information of the provision of services in the Home. Assessments of need were always provided when new Service Users were admitted to the Home, whether they were referred by Care Managers or were self-funding Service Users. EVIDENCE: A new statement of purpose had been developed for the Home. However, it did not fully comply with Schedule 1 of the Care Homes Regulations and considerable additional information was required. The additional information also needed to include the physical environment standards that were addressed by the Home. The Registered Providers had also completed an improved Service Users Guide to the Home, which addressed many issues a new Service User may have. However, it would be further improved by providing Service Users views on what it is like to live in the Home. The Registered Providers contract/terms and conditions of residency were examined, and these were found to be appropriate. However, they did not
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 10 include a section detailing with the rights and obligations of the Service User and Registered Providers and who would be liable if there were a breach of contract. When new Service Users were admitted to the Home, the Registered Provider/Manager was provided with a summary of needs of each person, completed by the Care Manager supporting each Service User. If the Service User was self-funding the Registered Provider/Manager completed her own summary of need. Standard 6 does not apply to this Home. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11. Service Users’ health and personal care needs were not being fully met, as there was insufficient information in care plans. Medication was appropriately distributed to meet Service Users needs. EVIDENCE: The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 12 To help assess Standard 7, The Service User Plan, the Inspector examined the records of four Service Users, for the purpose of case tracking. It was found that much of the basic information was provided. However, the preferred names of the Service Users were not recorded, and the name of the key worker was not included in three of the files. Three of the files had the initial assessments made by the Care Managers who placed each Service User within the Home, and three of the files also had the initial assessments completed by staff employed at The Firs. All of the files had the Contract/Statement of Terms and Conditions of Residency made between the Registered Providers and the Service User within them. The individual plans of care for three Service Users were very brief or not available. Only three of the files contained risk assessments for each of the Service Users. Staff in the Home had just started to complete a monthly review of care for each Service User. There was no indication that Service Users or their representatives had been asked about the limitations that might need to be placed upon their choice, freedom or decision-making. It was found that none of the files contained a review of care carried out by the Social Services Dept or by the Home itself. No files had evidence to show that the Service Users had seen their own file or agreed its contents. Regular recording was provided in each file, and the Registered Provider/Manager reviewed the files at regular intervals, which was evidenced by her signature. All three files were easy to read and the Registered Provider/Manager kept the files in a safe location in the Home. None of the files had a confidential section within them, and they were also poorly organised with no section dividers. Lastly, no Service User was provided with confirmation, in writing from the Registered Providers, to say that the services provided at The Firs were suitable to meet the Service User’s assessed needs in respect of their health and welfare. It was found that the records of Service Users health needs were appropriately maintained. The details of Service Users medication needs were examined and in general a good record was maintained. However, signature gaps were found in the Medication Administration Records (MAR), which also did not show that the Registered Provider/Manager had addressed the errors. When the MAR sheet indicated that one or two medications could be given to a Service User, staff did not record how many medications they actually gave. Two Service Users were spoken to 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 views/wishes. Their care needs were always
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 13 met with dignity and respect. As a result, they said they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. Service Users said that their plans for their funerals had been made with family, and that as far as they were aware the Registered Provider/Manager was not aware of the plans. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 14 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) 12, 13, 14 & 15. Service Users’ preferred lifestyles were respected by the Home. They were able to receive visitors and to exercise choice and control over their lives. Service Users were given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: The two Service Users spoken to said that they could go to bed and get up at times of their own choosing. That breakfast was available through most of the morning, and that this could be taken in their bedroom if they so chose. At all meals they said a choice was provided. They also said that they could choose or change their bath times. The two Service Users said that no one at the Home influenced them on how to spend their money. The Service Users were aware of their key workers, and said that their key worker would go to the shops for them if necessary. They said that trips out were organised at regular intervals, such as to garden centres. Entertainment and handicrafts were regularly provided in the Home, and an Activities Coordinator visited the Home twice a week. Relatives and friends were able to visit at any time, and could be seen in the privacy of their bedrooms. When the Service Users were in their bedrooms they said that staff always knocked and waited to be invited in. They said that
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 15 their mail was always delivered unopened. Service Users said that this was a none smoking Home. The two Service Users commented that they were very pleased with the new Registered Providers. They said that they could talk to them and that the Registered Providers listened and that as a result the Home had a good, friendly atmosphere. They also said that staffing had been changed and that this had improved the relationship between staff and Service Users. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 16 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) 16 & 18. The Registered Providers provide a good response to Service Users complaints, which enables Service Users to feel confident about the care provided, although verbal complaints were not recorded. EVIDENCE: Both Service Users spoken to said that if they wished to make a complaint they would do so to the Registered Providers, in whom they had considerable confidence. Both Service Users were very confident that their concerns would be appropriately addressed, although neither had chosen to make a complaint, up to the time of this inspection. The Registered Provider/Manager maintained a record of written complaints made, although none had been presented during the current Registered Providers ownership of the Home. However, verbal complaints were not recorded. The Registered Provider/Manager had an Adult Protection procedure that included a ‘Whistle Blowing’ policy. She also had copies of the Public Interest Disclosure Act of 1998 and of the Dept of Health’s policy called ‘No Secrets’. She also confirmed that the Home would follow up all allegations and incidents of abuse promptly and that all actions taken by staff would be recorded. The policies and practices laid down by the Registered Provider/Manager ensured that all staff understood physical and verbal aggression by Service Users. She said that there was a policy available to staff stating that they could not benefit from Service Users wills. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26. The Registered Providers had done much to improve conditions in the Home, and Service Users lived in comfortable surroundings. EVIDENCE: Since taking over the Home, earlier this year, the Registered Providers have done much to improve conditions within the Home, although there was much still to do. The following items were notified to the new Registered Providers, when they took over the Home, and needed to be urgently addressed. 1. Towels were found to be left on Service Users handrails, particularly in toilets. 2. Screening was not provided for Service Users around washbasins in double bedrooms. 3. Two Service Users bedrooms required curtaining to be provided across windows that opened on to the corridor on the first floor.
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 18 4. The first floor corridor carpet was found to be worn in many places and was in need of replacement. 5. All bedroom doors were not fitted with appropriate locks. 6. Comfortable seating for two people, in single bedroom, and for four people in double bedrooms was not provided. 7. The radiators in Service Users bedrooms were not safeguarded to prevent a Service User falling on them and badly burning themselves. 8. Two double socket should be provided in each single bedroom and four double sockets in double bedrooms. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27 & 28. The Registered Providers were found to be providing more than adequate staffing in the Home, in relation to the current Service Users numbers and their dependency. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during two weeks beginning 30 June 2005 the Home was providing between 17 and 17.5 hours of care a week more than the minimum amount required for 20 Service Users at the Medium Dependency level. The Registered Providers were reminded that by December 2005 at least 50 of care staff need to have obtained an NVQ level 2 qualification in Care. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 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 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) 31, 33 and 38. The overall management of the Home needs to be supported by the Registered Provider/Manager obtaining relevant qualifications and the second Registered Provider ‘inspecting’ the Home on a regular basis. This is to ensure on going Service Users security. EVIDENCE: The following issues were items discussed with the Registered Provider/Manager at the time of the inspection. The Registered Provider/Manager said that she was about to start her NVQ level 4 qualification in Management and Care. However, she also said that the second Registered Provider did not ‘inspect’ the home on an unannounced basis at monthly intervals of time. The Registered Provider/Manager said that as yet she had not developed a Quality Assurance system to operate in the Home.
The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 21 There was at the time of the inspection no system for measuring the temperature of the water used in baths for Service Users. Therefore the Registered Provider/Manager could not be sure that the temperature of bath water was 430 C or - 20 C. The Registered Provider/Manager did not have copies of the following legislation made available by the Environmental Health Dept - Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Registered Provider/Manager also said that she had not completed risk assessments on all working practice topics for staff or ensured that the finding were recorded and acted upon. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 3 2 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x 1 x x x x 2 The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Registered Providers must ensure that the statement of purpose contains all of the issues listed in Schedule 1 of the Care Homes Regulations, including the physical environment standards listed in Standard 1. The Registered Providers must include in the statement of terms and conditions/contract for living in the Home, information on the rights and obligations of the Service User and Registered Providers and who would be liable if there were a breach of contract. Each Service Users file must contain the assessment of need provided by the Care Manager, if the Service User was sponsored by Social Services Depts. Each Service Users file must contain an initial assessment of need completed by staff at the Home shortly after admission of the Service User. Risk assessments must be carried out for each Service User in the Home. Plans of Care for each Service User must be detailed, covering
C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Timescale for action 17 August 2005 2. OP2 5 17 August 2005 3. OP7 14 17 August 2005 4. OP7 14 17 August 2005 5. 6. OP7 OP7 13 15 17 August 2005 17 August 2005
Page 24 The Firs Residential Home Version 1.40 all aspects of need. 7. OP7 17 & Sch 3 Each Service Users file must contain details of the limitations placed on Service Users, as agreed by each Service User or their representative, on the Service User’s ability to make choices, liberty of movement and power to make decisions. All Service Users files must contain regular reviews of care undertaken by the Home. Each Service User’s file must contain information from the Registered Providers to say that the services provided in the Home are suitable to meet the Service User’s assessed needs in respect of their health and welfare. When signature gaps are left in the Medication Administration Record (MAR) sheet by staff the Registered Person/Manager must record on the back of the MAR sheet how this issue has been resolved. The Registered Provider/Manager must ensure that staff record on the MAR sheet how much medication was dispensed to Service Users when the MAR sheet says, for example, dispense ‘one or two’ medications. The Registered Providers must ensure that all Service Users are spoken to about their funeral plans and that these are recorded within each Service User file. The Registered Providers must ensure that all complaints, both written and verbal complaints, are recorded and positively acted upon. The outcome, following the complaint, must also being 17 August 2005 8. 9. OP7 OP7 14 14 17 August 2005 17 August 2005 10. OP9 13 17 August 2005 11. OP9 13 17 August 2005 12. OP11 12 2 September 2005 13. OP16 22 17 August 2005 The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 25 recorded. 14. OP19 12 & 23 The Registered Providers must provide curtaining across the two windows that open on to the first floor corridor from two Service Users bedrooms. The curtaining must be drawn in the evening when each Service User moves into their bedroom. (This Standard should have been addressed by 31 May 2005) Towels must not be left on Service Users handrails. Towel rails must be provided in all toilets close to the washbasin. (This Standard should have been addressed by 31 May 2005) The Registered Providers must ensure that all double bedrooms are provided with screening around the washbasins. (This Standard should have been addressed by 31 May 2005) The Registered Providers must provide two double electric sockets in single bedrooms and four in double bedrooms. (This Standard should have been addressed by 31 May 2005) All bedroom doors must be fitted with a lock that can be operated from both the inside and outside of the room by the Service User. Each Service User must be provided with a key to their bedroom. Risk assessments must be carried out and recorded in the Service User’s file where it is considered by the Registered Providers that the Service User is not able to hold the key to their bedroom. (This Standard should have been addressed by 31 May 2005)
C52 C02 S63245 The Firs V235336 220605 Stage 4.doc 17 August 2005 Previously this was required by 31 May 2005 15. OP19 23 16. OP19 12 & 16 17. OP24 16 18. OP24 12 17 August 2005 Previously this was required by 31 May 2005 17 August 2005 Previously this was required by 31 May 2005 17 August 2005 Previously this was required by 31 May 2005 17 August 2005 Previously this was required by 31 May 2005 The Firs Residential Home Version 1.40 Page 26 19. OP25 13 20. OP31 26 21. OP33 24 22. OP38 13 23. OP38 18 24. OP38 18 The Registered Provider must ensure that all radiators and pipework in Service Users bedrooms are provided with covers to safeguard Service Users. (This Standard should have been addressed by 31 May 2005) The 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. The Registered Providers must develop an annual plan for the Home including a quality monitoring system. The Registered Providers must ensure that hot water coming from bath hot taps is no hotter than 43 degrees centrigrade C or - 2 degrees centigrade. The Registered Providers must ensure the services provided by the Home comply with the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Registered Provider/Manager must provide risk assessments on all working practice topics in order to ensure that significant findings are recorded and acted upon. 17 August 2005 Previously this was required by 31 May 2005 17 August 2005 17 August 2005 17 August 2005 17 August 2005 17 August 2005 25. 26. The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 27 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. 4. Refer to Standard OP1 OP7 OP7 OP7 Good Practice Recommendations The Registered Providers should include in the Service Users Guide information from Service Users on their views of staying in the Home. Each Service Users files should contain the preferred name of the Service User. The name of the Key worker responsible for the Service User should be recorded in the front of each file. Those Service Users who are able should be shown their files at monthly intervals, by the key worker, and encouraged to sign them to confirm that this has happened. The Registered Providers should maintain a ‘Confidential’ section in each file, as necessary. Service Users file should be well-organised with different sections. The Registered Providers should replace the first floor corridor carpet, as it is worn in a number of places. (This Standard should have been addressed by 31 May 2005) All single bedrooms should be provided with comfortable seating for two people. However, this could be discussed with each Service User, or their Representative, and comfortable seating for one person could be provided if they agreed, and if this was recorded within each Service User’s Care Plan. This should also be done for Service Users in double bedrooms. All care staff and domestic staff should be provided with master keys to Service Users bedrooms. The Registered Providers need to ensure that at least 50 of care staff have at least an NVQ level 2 qualification in Care by 31 December 2005. The Registered Provider needs to ensure she obtains a qualification in Management and Care at NVQ level 4 as soon as possible. 5. 6. 7. 8. OP7 OP7 OP19 OP24 9. 10. 11. 12. OP24 OP28 OP31 The Firs Residential Home C52 C02 S63245 The Firs V235336 220605 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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