Inspection on 24/08/06 for The Flowers Hall

This inspection was carried out on 24th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Flowers Hall 17/07/07

The Flowers Hall 22/11/05

The Flowers Hall 29/06/05

The Flowers Hall 02/11/04

The Flowers Hall 13/07/04

The Flowers Hall 22/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Flowers Hall 80 Lascelles Hall Road Kirkheaton Huddersfield West Yorkshire HD5 OBD Lead Inspector Jacinta Lockwood Unannounced Inspection 24th August 2006 08:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Flowers Hall DS0000026275.V309248.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 Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Flowers Hall Address 80 Lascelles Hall Road Kirkheaton Huddersfield West Yorkshire HD5 OBD 01484 424184 01484 424184 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) Mrs Christine Anne Matthews Mrs Christine Anne Matthews Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: The Flowers Hall is a privately run residential home providing personal care and accommodation for up to twenty two older people on the outskirts of Huddersfield. The home is set in its own grounds, reached by a private driveway. There is parking to the front of the building and a garden for service users to the rear. There is a lack of public transport to the care home. Accommodation is provided on two floors with bedrooms on the ground and first floor, which can be accessed by a passenger lift. Both shared and single rooms are available. The home is staffed 24 hours a day. Wakeful night staff are on duty and an on-call system is in operation. The Commission was informed that as at 24.08.08 the home’s weekly fees ranged from £350 to £400. Additional charges are made for things such as chiropody, hairdressing, in-house shop and contributions to outings. Information about the home and the latest Commission for Social Care Inspection report are available from the home. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, one inspector made an unannounced visit to The Flowers Hall on 24.08.06. The visit started at 08:45 and ended at 18:20. During the visit, the inspector spoke with seven residents, two visiting relatives, a visiting healthcare professional, four staff and the registered provider/manager. Prior to this visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to a sample of 10 service users at the home, 6 were returned; their next of kin/representative, four were returned; the residents’ GPs, one was returned, eight social care professionals, none were returned. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection, for example, notifiable incident reports when service users are involved in an accident or incident. The home’s manager also returned a completed pre-inspection questionnaire to the Commission prior to the visit. The records of three service users were inspected, including care plans, risk assessments, medication and any monies and accounting records held by the home. Other records sampled included the food menu, complaints log, staffing rota, staff recruitment and training records, health and safety records, maintenance records and some policies and procedures. A partial tour of the building was made, including the bedrooms of three service users whose care was casetracked as part of the inspection. The inspector would like to thank all those who contributed to the inspection process. What the service does well: The Flowers Hall provides a homely and comfortable environment and residents expressed satisfaction with their accommodation. A relative reported that it was “A very good quality care home”. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 6 Staff were observed to approach residents in a kind and caring manner and to respect residents’ privacy and dignity. Residents, who looked well groomed and cared for, made positive comments about staff and one resident said that it was “like a family”. Residents are encouraged to express their views about the home and to contribute their ideas about the types of activities provided and to menu planning. Positive comments such as “the meals are excellent” were received. A resident spoke enthusiastically about the ‘motivation exercises’ and activities provided within the home and within the community. Prospective residents are able to visit the home before making a decision to live there and information about the home is provided to them. What has improved since the last inspection? What they could do better: Record keeping is a weakness of the home and improvements need to be made so that required information is available for inspection. Not all staff currently working at the home have received all the necessary training so that they have the skills and knowledge necessary when providing care to older people. There are a number of care and ancillary staff vacancies that need to be recruited to so that the registered manager does not spend so much time working care shifts and so that she can focus on the day to day management of the home. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 7 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 Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 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 the following standard(s): 3 The needs of prospective residents are assessed before they are offered a place at the home and a contract/statement of conditions provided as confirmation that their needs can be met there. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Flowers Hall does not provide intermediate care; therefore Standard 6 is not applicable. A community care assessment is obtained before a resident is admitted to the home. A senior member of staff also visits prospective residents to carry out an assessment. Prospective residents may visit the home before deciding to move there and a resident confirmed that a visit had been made and information provided about the home. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 10 A contract and statement of conditions is provided as confirmation of the placement. Residents who returned surveys indicated that they had received a statement of terms and conditions with the home. Copies were also held on residents’ files. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10 Service users have a care plan which sets out their needs. Service users’ health care needs are met. Medication is generally dealt with appropriately. Service users are treated respectfully and their privacy maintained. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care plans and associated documents of three residents were inspected. Risk assessments and care plans were in place and there was evidence of these being reviewed. Generally, there was a good level of information in the care plans. However, one care plan lacked specific detail regarding the management of a resident’s healthcare need. It was also evident from discussion with staff that they had a different understanding of what was meant by ‘high’ blood sugar levels and therefore when to contact the relevant healthcare professional. Care plans should be detailed and specific. Entries such as ‘check blood sugars 2-3 times weekly’ are not helpful and according to records, the resident’s blood sugars had not been checked as often as was required. A recommendation about care planning is made within this report. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 12 Daily reports generally reflected the residents’ plan of care but the records do not provide sufficient evidence that the action taken by staff meets the objective of the care plan. The daily report should inform the reader whether or not the necessary actions, as stated in the care plan, have been effective. A recommendation about recording in daily reports is carried forward within this report. A visiting healthcare professional reported that any advice given is included in the residents’ care plan and that staff act upon this. Records show that advice from healthcare professionals is included in the residents’ plan. A GP survey indicated that staff demonstrate a clear understanding of residents’ care needs. Residents spoken with expressed satisfaction with the care received at The Flowers Hall. Within the surveys two residents indicated that they always receive the care and support they need while four residents said they usually do. All residents indicated that staff listen to them and act upon what they say. Staff spoken with were able to explain residents’ care and support needs. They were observed to meet residents’ needs in a warm and caring manner and it was positive to hear staff explaining to residents what they were doing when they were assisting residents with transfers or to mobilise. Good practice was observed regarding the administration of medicines. Medicines information is noted on residents’ care plans. Three samples of medication were checked. The majority, including controlled drugs, were easily reconciled with records held, however, some stock of analgesic medication and food supplements had not been entered into stock. And a record had not been maintained of the administration of food supplements. A requirement about this is made within this report. A previous recommendation regarding the development of a self medication policy and procedure has been addressed. At present no residents self medicate. Staff were observed to treat residents with respect and to promote their dignity. A visiting healthcare professional also said that staff promoted privacy and dignity as did residents spoken with. Relatives spoken with and those returning surveys expressed satisfaction with the care provided at The Flowers Hall. One relative commented that “we are satisfied with (relative’s) care”. A resident said that she “likes it here”; that “it’s like a family”. The Flowers Hall DS0000026275.V309248.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): 12, 13, 14, 15 Residents maintain contact with family and friends and have opportunities to access community based facilities. Residents are helped to exercise choice. A range of activities is available to them. The food provided is varied, well balanced and enjoyed by residents. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A range of activities is provided for residents, details of which are on display in the entrance area of the home. This is a place where residents like to sit and watch the comings and goings throughout the day. Survey results indicate that two residents feel activities are ‘always’ arranged that they can take part in; three indicated they ‘usually’ were and one indicated that they ‘sometimes’ were. Residents are consulted at residents’ meetings and through the home’s quality survey about the types of activities they prefer. The home’s survey shows that residents would like more outings to the pub, garden centre and shopping and for piano and classical music. A range of library books and videos were also available. A relative commented that “staff work hard and often take the residents out shopping or to a show”. A resident said that she enjoyed going to Church, shopping and taking part in motivation exercises at the home. Some residents also take part in outings with relatives. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 14 Residents and relatives said that visitors were made welcome when they visited the home. It was evident from discussion with residents and observation that they can exercise choice, for example, regarding times of rising, clothing, how and where they spend their time and food and drink. Food choices are available at meal times and the menus indicate that a well balanced and varied diet, including fresh fruit, vegetables and salads are provided. Special diets are provided to meet residents’ needs. Residents expressed satisfaction with the food and the home’s quality survey supports this and notes that residents are consulted about the menu. Meal times were relaxed with residents being given enough time to finish their meal. The tables were set with tablecloths, napkins and condiments and residents were encouraged to choose and help themselves to breakfast cereals. Where residents required assistance to eat this was given in a discreet manner, with staff sitting with the resident. The dining room overlooks the garden and receives good natural light. The Flowers Hall DS0000026275.V309248.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): 16, 18 Residents and their representatives can be confident that their complaints will be listened to, taken seriously and acted upon. Generally, residents are protected from abuse. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home’s complaints log shows that concerns and complaints are taken seriously and acted upon with the timescales noted in the home’s complaints procedure. However, some documentation had not been fully completed and the outcome of some investigations hadn’t been recorded. A recommendation regarding this is made within this report. The complaints procedure is on display in the home’s entrance area together with leaflets for people to record any concerns or complaints. As discussed with the registered provider/manager, it would be useful to include the home’s telephone number on the leaflet and a recommendation regarding this is made within this report. It was evident from contact with residents, relatives and healthcare professionals that they know who to complain to should they have reason to do so. One relative reported that she had raised an issue with the manager and “she dealt with it immediately”. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 16 Relevant policies and procedures are in place. However, it would be useful for the telephone number of the local authority adult protection referral point to be included. A recommendation regarding this is made within this report. It was evident from discussion with staff that relevant action would be taken was abuse seen or suspected. Over 50 of staff have received adult protection training. All staff currently employed must receive training in adult protection to equip them with appropriate knowledge to promote the safety of service users and a requirement about this is made within this report. The Flowers Hall DS0000026275.V309248.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): 19, 26 Residents live in a generally safe, well-maintained environment, which is fresh and clean. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A limited tour of the building was made including the bedrooms of three residents ‘case-tracked’ as part of this inspection. There is stepped access at the front entrance to the home and disabled access at the rear of the home. The well maintained, secure gardens can be accessed from the dining room. At the time of this visit work was being completed to an aviary and decked area in the garden for the benefit of residents. Maintenance work is ongoing as is redecoration of bedrooms. Residents spoken with expressed satisfaction with the accommodation provided. And said that personal possessions could be brought into the home to make their private accommodation more homely. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 18 Equipment is provided to meet the diverse needs of residents in the home. Following a visit by the fire authority earlier this year, some fire safety work has yet to be completed. Also, one room, which is to be refurbished for use as a hairdressing room, is currently being used as a storage area, but there is no fire detection here. The need for fire detection in this room was discussed with the registered provider/manager at the time of the visit. A requirement regarding fire safety works is made within this report. On the day of this visit the home was clean and tidy. All those residents returning surveys reported that the home is fresh and clean, as did a relative. The Flowers Hall DS0000026275.V309248.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): 27, 28, 29, 30 Residents’ needs are met by staff at the home, half of whom have a National Vocational Qualification at level 2 or above. Some staff have not received all mandatory training to ensure they are trained and competent. Residents are supported and protected by the home’s recruitment practices. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are a number of care and ancillary staff vacancies at the home, which the registered provider/manager, Mrs Matthews, said were being recruited to. In the meantime vacant shifts are covered by agency or existing staff. At present, Mrs Matthews is working as part of the care team, which means she has little supernumerary time to focus on the overall management of the home. Mrs Matthews acknowledged this is an issue. It is recommended within this report that the registered managers’ hours be supernumery. Recruiting to vacant posts will support this and a recommendation about staff recruitment is made within this report. Although the carers on duty were able to meet resident’ needs without undue haste and had time to sit and engage with them, surveys from residents indicate that sometimes staff are not always available when they need them. Also, while two of the four relatives returning surveys indicated that sufficient staff are on duty to meet the needs of residents; two indicated this is not The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 20 always the case. Discussion with staff indicated that there is usually sufficient time to provide care and to have one-to-one time with residents. Staffing at the home is currently being re-structured and the registered provider/manager should take the above comments into consideration during this process. As noted above, recruiting to the vacant posts should improve the situation. The registered provider reported that 50 of staff have an NVQ (National Vocational Qualification) level 2 or above and training records supported this. A signed induction and foundation training record was available, but there was insufficient evidence that relevant workbooks are completed, as none were available for inspection. A recommendation is made for evidence of completed induction workbooks to be available for inspection. Induction should be in line with National Occupational Standards. Staff training is ongoing, but not all current staff have yet received mandatory training, for example, movement and handing, first aid, food hygiene, infection control and fire safety. Training records note that this is required urgently for some staff. During the inspection, both good and poor movement and handling of residents was observed. This was brought to the attention of the manager at the time and she addressed it with staff. However, a requirement is made within this report for mandatory training to be provided to current staff to ensure that they have the required skills and knowledge necessary when providing care to vulnerable older people. Recruitment records show that relevant checks are carried out before a person begins working at the home so that only those suitable to work with vulnerable people are employed there. The recruitment process was also confirmed in discussion with care staff. The Flowers Hall DS0000026275.V309248.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): 31, 33, 35, 38 The home is managed by a person who is fit to be in charge. The home is run in the best interests of the residents. Not all residents’ financial records are accurate. Generally, the health, safety and welfare of residents and staff are promoted and protected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Mrs Matthews, who is the registered provider and manager of The Flowers Hall, is experienced in the care of older people. It is evident from discussion with residents, staff and visitors that Mrs Matthews is approachable and supportive. One relative reported that when a concern was raised with Mrs Matthews, she dealt with it immediately. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 22 Residents and relatives have opportunities to comment on the service provided at the home through meetings, the home’s complaints procedure and through quality surveys. Positive comments about the home were available in the home’s quality report. A relative who returned a survey as part of this inspection wrote that The Flowers Hall is “A very good quality care home”. Two samples of residents’ monies were checked, one of which reconciled with records held; one did not as the amount in safekeeping was in excess of that recorded on the balance sheet. The registered manager was able to explain the reason for this; however, accurate accounting records must be held to clearly evidence that residents’ monies are safeguarded. A requirement about this is made within this report. A recommendation is also made for individual receipts to be kept with the residents’ monies as discussed with Mrs Matthews. Accident records are maintained as required. Records show that maintenance checks are carried out to ensure a safe working and living environment for staff and residents. However, there were gaps in recording the testing of the home’s fire safety system and a requirement about this is made within this report. From discussion with staff and records it was evident that some staff had recently received fire safety training from the fire authority. However, records at the home do not clearly evidence that staff have been involved in fire drills or received fire safety training twice in a twelve-month period. It is important that staff receive such training in relation to the environment in which they work. A requirement is made for all staff to receive such training and for detailed records of fire safety training and fire drills to be kept as recommended by the fire authority. The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 2 The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement All medication received into the home must be entered into stock and a record kept of when prescribed food supplements have been administered. All current staff who have not yet done so must receive training in adult protection. Fire safety works detailed in the fire officer’s report dated 08.03.06 must be completed within the timescale provided in the report. Confirmation that works have been completed must be provided to CSCI by the timescale opposite. The room to be used as a hairdressing room and currently used for storage must have fire detection within it. All staff currently employed who have not received basic mandatory training in movement and handling, first aid and food hygiene must do so. Staff must receive basic training in infection control. 31/01/06 not met. Timescale for action 02/10/06 2. 3. OP18 OP19 13(6) 24(40(c)(i ) 07/12/06 02/10/06 4. OP19 24(4)(c)(i ) 18(1)(c)(i ) 02/11/06 5. OP30 07/12/06 6. OP30 18(1)(c) (i) 07/12/06 The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 25 7. 8. 9. OP35 OP38 OP38 17(2) Schedule 4(9)(a) 23(4)(c)(v ) 23(4)(d) Accurate records must be kept of residents’ monies held for safekeeping at the home. Accurate and up-to-date records of fire system tests must be kept. All staff must receive suitable training in fire prevention twice each year. (Timescale of 21/09/05 and 11/01/06 not met). At a minimum all staff must have been involved in one fire drill and received fire safety training by the date opposite. Detailed records of fire safety training and fire drills must be kept as recommended by the fire authority. 02/10/06 02/10/06 07/12/06 The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP7 Good Practice Recommendations Care plans should contain detailed and specific information regarding residents’ care and support needs so that it is clear to staff what action they should take to support residents. Daily records should clearly evidence whether or not the residents’ needs identified in service user plans have been met and any changes. The complaints log should be fully completed including details of the action taken in response to a complaint and whether or not the complaint was upheld. The home’s telephone number should be included on the leaflets available to those wishing to make a complaint to the home. The telephone number of the local authority’s adult protection referral point should be included in the home’s adult protection procedure. The registered manager’s hours should be supernumerary. All vacant posts at the care home should be recruited to. Evidence of completed induction workbooks to National Occupational Standards should be available for inspection. Individual receipts should be kept on residents’ account sheet. 2. OP7 3. 4. 5. 6. 7. 8. 9. OP16 OP16 OP18 OP27 OP27 OP30 OP35 The Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Flowers Hall DS0000026275.V309248.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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