Inspection on 26/07/06 for The Firs Residential Home

This inspection was carried out on 26th July 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 Residential Home 02/07/08

The Firs Residential Home 16/07/07

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 26th July 2006 10:30 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 Residential Home DS0000063245.V299334.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.V299334.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.V299334.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. 7th February 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 this last year the Home has earned the Investors in People Award 2006, and currently holds the position of a Premium Rate home with the Derbyshire County Council. The charge made for a room at the Firs ranges from £296.00 to £360.00 a week. The Firs Residential Home DS0000063245.V299334.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 in just under 6.5 hours. Discussion was held with Residents, whose records were also ‘case tracked’, the Registered Provider/Manager and with a member of staff. A number of records were examined, and all of the Residents bedrooms and public areas of the Home were examined. What the service does well: What has improved since the last inspection? Since the last inspection, the Registered Providers have ensured that all complaints are or would be appropriately handled in the Home. The Registered Providers have also improved the physical appearance of the Home. New staff to the Home received appropriate foundation training, and training has been provided on Moving and Handling and First Aid. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Firs Residential Home DS0000063245.V299334.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.V299334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. The statement of purpose, Residents Guide and contract/statement of terms and conditions of residency were available, but did not provide Residents with all of the information necessary on the provision of services by the Home. EVIDENCE: The Registered Provider/Manager said that the Home’s statement of purpose had not been completed by providing the items that were found to be missing during an inspection held in June 2005. The Residents Guide had been completed, and contained information to inform Residents on how to make contact with the local Social Services Dept, the local Health Authority and with the Commission. However, it did not contain the recommendation that Residents view of the Home should be included. It was also found that the Registered Providers had not provided a complete statement of terms and conditions of residency or contract for living in the Home, and this again had The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 9 been outstanding since June 2005. As a result of this, prospective residents were not adequately informed prior to moving into the home. When new Residents were admitted to the Home, the Registered Provider/Manager was provided with a summary of needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Registered Provider/Manager completed her own summary of needs. As a result of these two assessments, Residents’ needs would be appropriately met in the home. Standard 6 does not apply to this Home. The Firs Residential Home DS0000063245.V299334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. Residents’ health and personal care needs were being fully met, as demonstrated within care plans. Medication was distributed to meet Residents needs, although a number of improvements were required. 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. All of the basic information, concerning each Resident, was found to be in the files examined, although none of the files looked at contained the preferred name of each Resident. Copies of the initial assessment completed by the Social Services Care Manager, where one was involved, were available, and the Registered Provider/Manager had completed her own initial assessment of needs for The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 11 each of the three Residents. The files also contained copies of the contract signed by each Resident on admission. The files also contained copies of the ongoing care plan and risk assessment for each Resident. However, two of the files had not been updated during the past 18 months. The staff member interviewed, during the inspection, said that care staff reviewed the care plan with Residents on a monthly basis. Therefore, the two files without this data may have been exceptional. 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. This information should be reviewed and updated at least at each formal six monthly review held in the Home. The files showed that good records of events affecting each Resident were kept by the Home. The Residents were formally reviewed by the Social Services Dept on an annual basis, but only one Resident’s file showed that her needs had been formally reviewed by the Home on a 6 monthly basis. The Registered Providers are reminded that Residents (or their representatives) should be required to sign the 6 monthly and annual reviews of care. The records showed that this had not been done. All of the files were easy to read and had regular entries from the staff. They were well organised, although they did not contain a confidential section. Two of the files contained information on the Resident’s wishes following their death, but this was not included in the third file. In two of the files a staff member had asked other staff to carry out a particular regular task, but the task had not been referred to in later entries. It was therefore not possible to decide whether the request had been carried out. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents were examined, and a number of issues were found that needed attention: When staff needed to update an entry on the Medication Administration Record (MAR) sheet this needed to always be signed by two staff, stating the name of the Doctor who authorised the change and be dated. It should also be completed as a new entry on the MAR sheet. A number of signature gaps were found on the MAR sheets. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 12 In a number of places on the MAR sheets it was required that drugs be taken, for example, ‘4 times a day’. The record showed that the Resident was taking the drug less frequently than the required number of times each day. In a number of places on the MAR sheets an ‘F’ had been placed on the record, presumable to indicate that the drug could not be given for one reason or another. However, the meaning of the ‘F’ had not been defined at the foot of the MAR sheet. Some drugs were provided in medi-dose containers, and others were provided in bottles/sachets. The MAR sheet did not state which medications were contained in the medi-dose container and which were in bottles/etc. As a result medication might not be given to a Resident, under the belief it was all contained in the medi-dose container. In some Residents bedrooms prescribed creams were found on the dressing tables etc. All medications should be kept locked away at all times. One Resident was spoken to about life in the Home. She said that staff were very good at listening to her views on how she liked to be cared for and staff would carry out her wishes. She said that her care needs were always met with dignity and respect. As a result, she felt very safe in the Home, and appeared to have a strong sense and appearance of well being - ‘Staff always ask how I like things to be done, and do it the way I want.’ The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 & 15. The quality in this outcome group was ‘Excellent’. This judgement was made using available evidence including a visit to the Home. Residents preferred lifestyles were respected by the Home. Residents were also given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: One of the Residents was asked about the activities provided in the Home. She said that events included such things as a pianist and singer calling at regular intervals. Up to Christmas last year, an Activities Coordinator arranged activities twice a week, but sadly she had left and the Registered Providers had not been able to replace her. Staff now organise activities, but not as frequently. The Resident said she felt very safe living in the Home - ‘Yes, I have no problems.’ Staff respected her confidences and all her needs were met with dignity, respect and choice - ‘You could tell staff things in confidence, I could tell a few staff.’ The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 14 The Resident said that she could go to bed whenever they liked – ‘I choose the time I go to bed, and we can get up at a time of our own choosing, although you can stay in bed if you are unwell.’ The Resident also said that she could choose or change her bath times - ‘I shower once ever week, but I can have more if I wanted.’ The Resident said that meals were always good - ‘A choice is offered at all meals, they always ask you what you want from the menu’ – ‘If you don’t like something they always give you something else.’ During the inspection, a member of staff was observed going around all the Residents asking what they wished to have for tea from the menu. An able Resident was also known to regularly go to the shops for other Residents, and to help with buying ingredients for meals. The Resident said that she knew who her keyworker was. She said that the keyworker comes to her once a month and tells her what has been written about her in the Home’s records. She also said that she had seen her individual plan of care. According to the Resident spoken to, the Home knew what the Resident’s wishes and plans were at her death. The Resident said that she could go out to the shops whenever she liked – ‘I have a good family, they take me out regularly.’ Relatives and friends of Residents were able to visit at any time, and could always be seen in private ‘I can go to my room with my relatives, but I usually like to go out.’ The Resident said that staff always ‘knocked and wait for me to say ‘Come in’’ before entering her bedroom. The Resident said that her mail was always delivered unopened. She also said that this was a ‘no smoking’ home. If the Resident had a concern or complaint to make she said that she ‘would tell Yvonne (the Registered Provider/Manager), and it would be investigated, but I have never had to do this. There is a happy atmosphere here.’ The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 15 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): Standards 16 & 18. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Complaints and concerns made to the Registered Provider/Manager were appropriately addressed to meet Residents needs. The protection policies and procedures provided by the Home meant that Residents were well protected. EVIDENCE: The Resident spoken to said that if she had a concern or complaint to make she ‘would tell Yvonne (the Registered Provider/Manager), and it would be investigated, but I have never had to do this. There is a happy atmosphere here.’ The Commission had not received any notice of complaint since the last inspection of the Home in February 2006. Good procedures and satisfactory records were maintained of both verbal and written complaints. Since the last inspection two verbal incidents were recorded, which were satisfactorily resolved. The Home’s record also detailed that all complaints would be responded to by the Registered Providers within at least 28 days. The Registered Providers had an Adult Protection procedure that included a ‘Whistle Blowing’ policy. There were also copies of the Public Interest Disclosure Act of 1998 and the Dept of Health’s policy called ‘No Secrets’ The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 16 available in the Home. It was confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Registered Provider/Manager said that there was a policy available to staff stating that they could not benefit from Residents wills. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 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 the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Generally, the Home was well maintained throughout, however, improvements were needed to ensure all Residents lived in a well-provided and maintained environment. EVIDENCE: A tour was made of the Home, including all of the bedrooms of the Residents. The Home was reasonably decorated throughout, and the lounges and dining room were provided with appropriate items for the Residents. The bedrooms were well laid out with satisfactory space provided for each Resident. The garden was also well laid out and looked most welcoming. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 18 However, a number of items needed to be addressed within the Home: It was found that not all single bedrooms had been provided with two double electric sockets or all double bedrooms with four double electric sockets. This issue had been outstanding within the Home since June of 2005. In double bedrooms 3 and 6 no curtaining was provided around the washbasins, to protect the privacy of Residents when washing themselves. Bedrooms 2 and 3 were used by the Hairdresser as the salon for hairdressing for all Residents in the Home. It was deemed inappropriate to use Residents private bedrooms in this way, and the Registered Provider/Manager was urged to find an alternative position for the Hairdresser to use. One bedroom was found to have a poor odour. In bedroom 7, 14 and in the toilet at the top of the main staircase radiator covers were needed to protect Residents from possibly burning themselves. In the bathroom opposite to bedroom 9 and 9a, the emergency staff call line was not long enough to be reached by a Resident sitting in the bath. There was also no emergence staff call line provided by the shower in this bathroom. Also, in a number of toilets provided in Residents bedrooms, the emergency staff call line ended at least 3 foot from the floor, and as a result could not be reached by a Resident who might have fallen. Window safety devises need to be fitted to all bedroom windows on the first floor, to prevent confused Residents attempting to climb from the windows. Residents’ bedrooms were not fitting with door locks. All single bedrooms need to be provided with two comfortable seats for use by the Resident and their guest, and all double bedrooms with four comfortable chairs. Many single bedrooms were found to have only one comfortable chair and many double bedrooms to only have one or two comfortable chairs. A table to sit at was also needed in many bedrooms. During the inspection a staff member was observed using a Resident’s bedroom as a changing room. This was inappropriate behaviour and more appropriate facilities needed to be provided. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 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 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): Standard 27, 28, 29 & 30. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Care staffing was appropriately provided to meet the needs of Residents. However, Residents were not protected from potential harm by robust recruitment procedures. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the two weeks beginning 10 and 17 July 2006 the Home was providing more than sufficient staffing, and equated to 14 Residents at the Medium Dependency level and 5 at the Low Dependency level. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum, and therefore were meeting Residents needs. At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ level 2 in Care, and therefore met the expectation of the Commission. The records of the most recently appointed staff member were examined to see whether the Registered Provider/Manager had obtained all relevant information about her. It was found that the Registered Provider/Manager had The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 20 only obtained one reference for the member of staff and not two, and a photograph had not been provided. The member of staff’s history of employment was not available in the file and neither was the member of staff’s opinion on her fitness to do the job required. The file did show CRB information, the member of staff’s qualifications and information about previous work for a caring agency. The Registered Providers therefore need to improve their records of the employment of new staff to the Home. Staff induction and foundation training was provided for all new staff that came to work in the Home. The Registered Provider/Manager said that all care staff were provided with at least three paid days training a year. All staff also had an individual training and development assessment and profile. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35, 36 & 38. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. The Registered Provider/Manager needed to address the Quality Assurance issues to ensure Residents care was maintained at a positive standard. Staff also needed regularly supervision and training to ensure that Residents needs could always be met. EVIDENCE: The Registered Provider/Manager had not as yet completed her NVQ level 4 qualification in Management and Care. The completion of the course was due at the end of December 2006, which will be well within the requirement laid down by the Commission when the Registered Provider/Manager took over the Home. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 22 The second Registered Provider was required, in the last inspection of the Home in February 2006, to begin formally ‘inspecting’ the Home to ensure that standards were maintained throughout. This was to include the necessary written record of his ‘inspections’. However, the Registered Provider/Manager said that the second Registered Provider did regularly ‘inspect’ the home, but did not complete the necessary formal record to support his ‘inspections’ of the Home. At the time of the last inspection of the Home, by the Commission, the Registered Providers said that they had not been able to address the Quality Assurance issues required by the Regulations and Standards. At this inspection the Registered Provider/Manager said that they had still not begun to address these issues. The Registered Provider/Manager was able to show that the personal money of at least two Residents, randomly selected, were maintained satisfactorily. However, she was holding sums of money considerably in excess of £100 for both of these Residents. She was recommended to liaise with the Social Services Dept, of the relevant local authority, to reduce these amounts to no more than £50.00 per person at a maximum. The supervision needs of the care team were discussed with the Registered Provider/Manager. She clearly stated that all care staff were observed while carrying out their duties, and showed the records of the supervision of individual care staff members. A good start had therefore been made on the supervision of staff; however, the care staff had not been individually supervised on the 6 occasions per year, as recommended by the Commission. The training provided for staff was examined. This showed that Moving and Handling training and Food Hygiene training were up to date for all relevant staff. The vast majority of staff had been trained in First Aid and Infection Control, although up to 4 members of staff still required this training. Fire Safety training had been provided once per year for all staff in the Home, although night staff had not been trained twice each year as required by the Fire Authority and the Commission. The Commission also recommended that the Home ensured that at least one qualified first aider be on duty on every shift in the home, both day and night. The Registered Provider/Manager said that she was planning to achieve this shortly but that three staff were still awaiting this training. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Home had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 23 The Registered Provider/Manager had provided a written statement of the policy, organisation and arrangements for maintaining the safe working practices in the Home, but had not provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. The Registered Provider/Manager ensured that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She had also ensured, with the assistance of the Fire Service that fire safety notices were posted in relevant places around the Home. The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 24 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 2 The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 25 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 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. (This issue should have been addressed from the inspection report dated 22 June 2005) 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 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 Medication Administration Record (MAR) sheet must not contain signature gaps. The Registered Provider/Manager needs to regularly review the DS0000063245.V299334.R01.S.doc Timescale for action 20/09/06 2. OP2 5 20/09/06 3. OP9 13 20/09/06 The Firs Residential Home Version 5.2 Page 26 MAR sheet and discuss with staff the cause of any signature gaps and record on the back of the MAR sheet her actions. The instructions given on the MAR sheet for the frequency of medication must be followed on all occasions. When the letter ‘F’ is used on a MAR sheet the letter ‘F’ must be defined at the foot of the chart. Prescribed medications (creams) must not be left in Residents bedrooms. 4. OP19 12(4)(a) The Hairdresser must not use Residents bedrooms as the temporary hairdressing salon for all Residents in the Home. All bedroom doors must be fitted with a lock that can 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. Risk assessments must be carried out and recorded in the Resident’s file where it is considered by the Registered Providers that the Resident is not able to hold the key to their bedroom. (This Standard should have been addressed from the inspection report of 22 June 2005) The Registered Providers must ensure that all radiators and pipework in Residents’ bedrooms and toilets are provided with covers to safeguard Residents. (This Standard should have been addressed from the inspection report of 22 June DS0000063245.V299334.R01.S.doc 20/09/06 5. OP24 12 20/09/06 6. OP25 13 20/09/06 The Firs Residential Home Version 5.2 Page 27 2005) 7. OP29 19 The Registered Provider/Manager must check, and hold documentary evidence, that all staff employed in the Home, since April 2002, have satisfied the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004. 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. (This Standard should have been addressed from the inspection report of 22 June 2005) The Registered Providers must ensure that all night staff receive Fire training twice each calendar year. The Registered Provider/Manager must provide risk assessments on all working practice issues undertaken by care staff, catering staff and domestic staff. (This Standard should have been addressed from the inspection report of 22 June 2005) 20/09/06 8. OP31 26 20/09/06 9. OP38 18 & 23 31/10/06 10 OP38 18 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000063245.V299334.R01.S.doc Version 5.2 Page 28 The Firs Residential Home 1. Standard OP1 The Registered Providers should include in the Residents Guide information from Residents on their views of staying in the Home. The basic information contained in each Resident’s file should include the preferred name of the Resident. Each Resident’s care plan and risk assessment should be updated on at least a 6 monthly basis, and more regularly as the need arises. The Registered Providers need to ensure that each Resident, or their representative, has had the opportunity to discuss their rights to choice, freedom and decisionmaking while staying in the Home. The outcome needs to be recorded in each Resident’s records, at least on a 6 monthly basis. The Registered Providers should formally review each Resident on a 6 monthly basis. Those attending the review should include the Resident, their relatives including the representative, staff from the Home and the Registered Provider/Manager. Residents or their representative should be asked to sign the written copy of the review. Residents’ files should each contain a confidential section. Residents’ files should contain detail of their wishes following their death, such as the funeral director and whether they wished to be buried or cremated. When staff use the Resident’s record of events to ask other staff to carry out tasks, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. 2. OP7 3. OP9 When staff need to update an entry on the Medication Administration Record (MAR) sheet this should always be signed by two staff, state the name of the Doctor who authorised the change and be dated. It should also be completed as a new entry on the MAR sheet. The Registered Provider/Manager should discuss with the Pharmacist the recording of medication on the MAR sheet, and ensure that the MAR sheet indicates which drugs are contained in the medi-dose containers and which need to The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 29 be administered from bottle/sachets. 4. 5. 6. OP19 OP19 OP19 In bedrooms 3 and 6 curtaining should be provided around the washbasins to protect the privacy of Residents. The poor odour in the bedroom identified during the inspection needs to be resolved. The emergency staff call line, in the bathroom close to bedrooms 9 and 9a, must be lengthened so that it can be reached by a Resident using the bath. Also in this bathroom an emergency staff call line is needed by the shower. The emergency staff call lines in the private toilets in Residents bedrooms need to be lengthened so that they can be reached by a Resident who might have fallen to the floor. 7. OP19 Window safety devises need to be fitted to all bedroom windows on the first floor, to prevent confused Residents attempting to climb from the windows. Staff must not use Residents bedrooms as their changing rooms. The Registered Providers should provide two double electric sockets in single bedrooms and four double electric sockets bedrooms for two Residents. All single bedrooms should be provided with comfortable seating for two people or four people in double bedrooms. They should also be provided with a table to sit at for each Resident occupying the bedroom. However, this could be discussed with each Resident, or their Representative, and not provided if they agreed with this, and if this was recorded within each Resident’s Care Plan. All care staff and domestic staff should be provided with master keys to Residents bedrooms. The Registered Provider/Manager needs to obtain a qualification in Management and Care at NVQ level 4 by 31 May 2007. An effective quality assurance and quality monitoring system needs to be introduced. DS0000063245.V299334.R01.S.doc Version 5.2 Page 30 8. 9. OP19 OP24 10. OP24 11. 12. OP24 OP31 13. OP33 The Firs Residential Home 14. OP35 When the Home is holding personal money on behalf of Residents, it should not hold more than approximately £50.00, for each Resident, at any one time. The Registered Provider/Manager should carry out formal supervision of all care staff, at least 6 times a year. Mandatory training in Fire Safety, First Aid and Infection Control needs to be urgently provided. First Aider training should also be provided for senior staff, to ensure that at least one First Aider can be on duty in the Home day and night. 15. 16. OP36 OP38 The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Firs Residential Home DS0000063245.V299334.R01.S.doc Version 5.2 Page 32 - 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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